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The social work-medical-legal partnership: next-level collaborating

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The social work-medical-legal partnership: next-level collaborating

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Content The Social Work-Medical-Legal Partnership: Next-Level Collaborating

Margaret Holding
Capstone Project Paper
Presented to
725c Preparatory Scholarship for Capstone, Dr. Michael Rank, June 29th, 2023
Suzanne Dworak-Peck School of Social Work
University of Southern California
In Partial Fulfillment of the Requirements for the Degree of
Doctor of Social Work
August 2023

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Acknowledgments
I would like to thank my committee members – Dr. Michael Rank, Dr. June Wiley, and
Dr. Todd Hatley; singularly and collectively, you were more helpful than you know. I am
incredibly grateful to my advisor, Dr. Rank, who was willing to take me on as a 725 student to
jump right in the middle of my capstone work. His patience and invaluable attention have no
rival and I would not have finished this program without him. I was fortunate to have Dr. Wiley
my first semester; her equanimity and encouragement were wonderful gifts to this brand-new
DSW student. It was, in fact, her suggestion that planted the seed that bloomed into my capstone
project. And finally, I would like to express utmost gratitude to Dr. Hatley, even though it is
impossible to do so adequately. I was so blessed by your great wisdom, experience, and all the
time you clocked in as my external design partner. As a true systems-oriented, design thinking
expert, your input was invaluable and it was your dedication that got me over the finish line.
Much appreciation also goes to Dr. Bob McKinney, of University of Alabama, and
Allyson Gold, of Wake Forest University. Despite their busy schedules, they made themselves
available for collaboration to guide my capstone process and I am so very grateful for their
invaluable input. And, of course, a shout out to Dr. Terence Fitzgerald (Dr. T) for having my
back…I would not have made it without you!
I must also thank my sons for their support, meals, and guidance, as well as the valuable
lesson of perseverance. You guys will always be the greatest initiatives I was blessed to have a
central role in creating and I love you both dearly! My extended family as well – my sister, my
brother, and their families, were phenomenal these past three years and vital in keeping me going
with their loving encouragement. I am exceptionally blessed by all of you and am grateful to the
bottom of my heart.

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Table of Contents

EXECUTIVE SUMMARY ..................................................................................................................................... 4
POSITIONALITY STATEMENT ............................................................................................................................. 8
PROBLEM OF PRACTICE, SOLUTION LANDSCAPE, AND LITERATURE REVIEW ..................................................... 10
SOLUTION LANDSCAPE ................................................................................................................................... 16
CONCEPTUAL/THEORETICAL LANDSCAPE ........................................................................................................ 17
PROPOSED SOLUTION .................................................................................................................................... 23
IMPLEMENTATION PLAN ................................................................................................................................ 29
CHALLENGES .................................................................................................................................................. 34
CONCLUSIONS AND IMPLICATIONS ................................................................................................................. 35
REFERENCES .................................................................................................................................................. 38
APPENDIX A ................................................................................................................................................... 47
APPENDIX B ................................................................................................................................................... 48
APPENDIX C ................................................................................................................................................... 49
APPENDIX D ................................................................................................................................................... 51
APPENDIX E ................................................................................................................................................... 52
APPENDIX F ................................................................................................................................................... 53
APPENDIX G ................................................................................................................................................... 54
APPENDIX H ................................................................................................................................................... 55

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Executive Summary
Problem Summary
The persistent challenge of U.S. health disparities remains despite extensive research and
innovations, complicated by health-harming needs fueled by the broader, upstream determinants
of health. While specific wellness interventions and smaller partnerships offer some relief, a
multi-dimensional strategy with the skills of key professionals is needed for true progress.
Medical-Legal Partnerships (MLPs) which use the addition of lawyer expertise to address
patients’ health-harming legal issues, show promise for effective intervention but have
limitations in addressing other damaging social needs. Social workers, with their clinical skills
and community ties, can greatly enhance MLP operations, but are often underutilized. Hence, by
incorporating social work leaders alongside doctors and lawyers, MLPs can become suitably
comprehensive to elevate their impact at multiple levels.
Capstone Project and relevance to Grand Challenges
In tandem, Eliminate Racism and Close the Health Gap, share a dynamic that causes
exponentially greater damage which reverberates through many of the other Grand Challenges of
Social Work (Grand Challenges of Social Work, 2023). As such, this dysfunctional pair wreak
havoc at junctures where discrimination and health disparities meet; in the wake of their joint
destruction, one can see the ensuing devastation in other wicked problems such as economic
inequality, homelessness and incarceration. Subsequently, a holistically based racism/health
disparities initiative successful in reducing their harmful effects could demonstrate even greater
positive impacts on other destructive societal issues.
To fulfill this challenge, an MLP approach with formal social work inclusion would
achieve better health outcomes for minority patients and impact mezzo/macro changes by

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enhancing community health and informing effective policy change. However, prospects do not
stop there. As greater strides are made in tackling racist health inequities there are larger
implications for improvements in communal ills that make up other Grand Challenges such as
social isolation or income inequality.
Design Thinking Methodology
Design thinking methodology was employed to develop the Social Work-Medical-Legal
Partnership (SWMLP) initiative. The process involved conducting extensive research and
gaining valuable insights from stakeholders to identify opportunities to enhance MLP operations
by incorporating social work skills. Design criteria and concepts were then utilized to guide the
visionary process in building this initiative. The final prototype of this capstone project is an
online learning collaborative that offers practical guidelines for MLP expansion to implement a
revised SWML Partnership. This collaborative consists of three weekly sessions offering
suggestions for implementing social workers into MLP operations. Participants will have access
to various resources, including class materials, recordings, and an online discussion forum, to
facilitate learning and shared knowledge.
Capstone Project Goals
The proposed solution aims to achieve enduring changes by adopting a systems
perspective which acknowledges that complex issues of racism and health inequities require a
multifactorial, multi-tiered approach to effect meaningful change. The SWMLP initiative intends
to decrease health disparities and improve health outcomes for people of color by fully
addressing the social determinants of health (SDOH) by integrating a social worker into MLP
functioning. The goals of the initiative are timely given the current focus on health equity,

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SDOH and their impact on well-being, and the need for a more comprehensive approach to
healthcare.
Proposed Solution Description
To address these complex challenges, this collaborative, developed in partnership with
the National Center for Medical-Legal Partnership (NCMLP), will be offered on their national
platform. The curriculum is designed to be completed over a three-week period, with each week
focusing on three main topics of social work incorporation – integration phase, adjusted
workflow and ongoing considerations. During individual sessions, detailed steps offer specific
ideas to address processes being covered that week. Panel experts will lead an interactive type of
forum to allow for questions and discussions. Additionally, participants will receive digital
materials and resources to complement pertinent subject matter.
Alignment with Best Practices
Best practices of current partnership-based initiatives were considered in the research and
development of a more inclusive, ambitious alliance for health equity work. Barriers these
programs encountered that interfered with more prosperous outcomes, as well as factors
facilitating achievement, were informative in building on their work. This knowledge was
helpful to, not only devising enhanced techniques to maximize results, but also methods to
address impediments that may interfere with success and scalability.
Capstone’s Professional Significance
Once implemented, the SWMLP initiative to increase social work’s role in MLP
practices could have positive impacts for minority patients, their neighborhoods and entire
populations. This is due, in part, to the way in which this intervention embodies the theory that
fueled its development: a holistic, systems-based perspective on how medical care should be

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considered and dispensed for everyone. As this method is employed more and more, ripple
effects may include shifts in current, ineffective norms in U.S. healthcare today, thereby creating
ambitious macro improvements that could encompass many medical care facilities.
Conclusion
To sum, the SWMLP initiative offers a promising solution to address health disparities
and promotes equitable health outcomes for marginalized populations. By integrating social
work alongside medical and legal professionals, MLPs can become more comprehensive and
thus more effective in addressing the broader social needs of their patients.

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Positionality Statement
For a social worker, a positionality statement seems ironic - list ways we identify
ourselves, and yet, we are careful labeling others. Regardless, people categorize one another; it is
an adaptation inherent to our nature. Unfortunately, though, frequent inaccuracies detrimentally
affect those wrongly labeled and impact what they experience, how they regard themselves and
who they become. So, I may not want to designate myself, but need to appreciate others will, and
always have, just as I have done the same. In this context, my view of self and how I fit into the
world is formed, and in the process have learned inaccurate labels are often undeservedly
fortuitous for some, unfairly prejudicial for others.
I am a White, middle-aged, heterosexual, woman and mother, born and raised in an upper
middle-class home in North Carolina. Based on these descriptions, I am easy to classify and
subject to subsequent assumptions; some may even be true. For instance, I certainly benefitted
from a privileged upbringing as a Caucasian of economic means and continue to do so. I am not
a stranger, however, to traumatic childhood experiences. For this reason, I empathize with those
who suffer, especially the most vulnerable among us. Unjustifiably though, advantages afforded
me access to coping mechanisms not available to more deserving, yet disadvantaged individuals
- typically people of color.
Growing up, I recognized as a White Southerner I was gifted with random, unearned
assets, but I also witnessed the damaging, unfair, arbitrary labels imposed on Black individuals.
Later, during my graduate psychology program, I learned its contribution to fundamental
attribution error and the ease in which people could claim prejudicial fallacies, such as, Black
people have higher unemployment rates because they are “lazy” or poorer health outcomes due
to “unhealthy habits.” Conveniently and unsurprisingly, these racist philosophies often free non-

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Blacks of sympathy or responsibility and the self-serving nature of racism creates attitudes and
inclinations difficult to change. So, to disrupt these harmful social norms and offer respite to
disadvantaged minorities, my initiative aims to alleviate health harming social needs that help
serve to make them targets for bigotry. For example, a Black man, with no means of travel, may
struggle with full-time employment due to uncontrolled diabetes, not laziness. When offered
reliable transportation for medical care, better health outcomes contribute to his job security.
It is not without irony I realize the circumstances that allowed me access to graduate level
social work studies. White privilege is certainly not required to pursue a Doctor of Social Work
degree, however, it greatly eased my passage here. Once again, financial security and
unwarranted opportunity came to my assistance, though my hope is to be successful using it to
make positive changes for those unfairly marginalized.

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Problem of Practice, Solution Landscape, and Literature Review
Problem Statement
Racism is a culprit in many societal ills but plays a particularly toxic role in health
disparities (Akinade et al., 2022; Anderson et al., 2009; Bailey et al., 2021; Hanks et al., 2022;
Mateo & Williams, 2021). Literally adding insult to injury is when minorities, struggling with
serious and chronic health problems, are unable to fully function and then are negatively judged
as a result (Priest et al., 2018). Therefore, in tandem, Eliminate Racism and Close the Health
Gap, cause exponentially greater damage playing a role in many of the Grand Challenges of
Social Work (Grand Challenges of Social Work, 2023). Unfortunately, despite the determination
of many to improve health care in this country, the U.S. still scores very poorly in this domain
and the health gap is wider and more pervasive than ever before (Bradley et al., 2011; Browne et
al., 2017; Papanicolas et al., 2018).
Particularly troubling is the dysfunctional feedback loop minorities find themselves in
(Braverman et al., 2011; Brown et al., 2019). To wit, enduring discrimination has deleterious
effects on minority’s health creating a greater need for costly medical care, yet many lack the
necessary funds (Mateo & Williams, 2021; Shrank et al., 2019; Venkataramani et al., 2020).
Poor health outcomes lead to work absenteeism, further weakening financial stability, putting
healthcare even further out of reach. These ever-increasing challenges then keep impoverished
minorities on the low end of socio-economic status (SES) and ensure their place in marginalized
communities - all of which continue to make them targets for bigotry. Consequently, the toxic
dance begins again, and this feedback loop of racial bias and health disparities serves to keep
minorities unhealthier, disenfranchised and at a distinct disadvantage for upward mobility.

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The concept behind this phenomena is not only discrimination’s role in SDOH and the
social needs they create downstream (Paradies et al., 2013), but also how this unfortunate
process is circular in nature. Specifically, lack of social goods such as adequate housing or food
access are deleterious to well-being; ill health, in turn, creates greater challenges for minorities to
successfully attend to these racially driven disadvantages (Braveman et al., 2011). To assist in
this, the MLP approach has evolved to enhance medical care by tackling patients’ legally related
social needs to improve patient outcomes (Tames et al., 2003). MLPs as currently structured,
though, can neglect other Black individuals’ health-harming needs that fall outside the scope of
medical and legal practice leaving these patients without necessary resources to improve health
outcomes which then reduces their chances for upward mobility. Thus, the wicked problems of
racism and health disparities, and their tentacles of destruction, can continue to flourish,
unimpeded.
Scope of Problem and Impact on Target Population
While minorities continue on medical racism’s damaging merry-go-round, so do requisite
health disparities and unfathomably, they begin at birth. Overall, the U.S. infant mortality rate
has dropped, however, Black infants continue to die three times the rate of White newborns
(Baciu et al., 2017; Greenwood et al., 2020; Riddell et al., 2017; Rossen et al., 2016). As they
grow, young minorities continue to experience significant inequities. Black children are less
likely to be diagnosed with ear infections or given antibiotic prescriptions (Gerber et al., 2013)
and receive fewer pain medications when struggling with injuries or debilitating disease (Goyal
et al, 2020; Linton & Feudtner, 2008). Things continue to look bleak for minority youth as they
come of age. Among adult patients with heart disease, Black individuals are given older and
cheaper treatments, compared to Whites. Furthermore, when these patients have cardiac surgery,

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it is more common for them to be discharged before it is safe in doing so (Bridges, 2018).
Unsurprisingly, glaring disparities remain up until the very end with those of high socioeconomic
status (SES) living an average of 15 years longer than those on the low end of the SES scale,
typically comprised of minorities (Daniel et al., 2018).
Racial health inequities are not only seen at every stage of life, but also span the spectrum
of morbidity. For example, patients of color are less likely to get kidney dialysis or transplants,
receive optimal treatment for strokes, cancer or AIDS and diabetics have a higher rate of limb
amputation than Whites. Mental health is no exception as Black individuals with bipolar disorder
are more likely to be prescribed ineffective and unsafe antipsychotics than White persons
(Bridges, 2018). The maternal mortality rate for Black women remains bleak as they die at 2-3
times the rate than White mothers ("Infographic: Racial/Ethnic disparities in pregnancy-related
deaths — United States, 2007–2016," 2022). African American men are also twice as likely as
Caucasians to die prematurely from stroke (Baciu et al., 2017).
Therefore, it is clear simply providing medical care to minority populations is not a cure-
all for achieving equitable health outcomes. A worthy consideration is this: to what extent do
social determinants/needs play a role in these discrepancies and to what degree are they tackled?
However, with regard to legally related social needs, they may go unaddressed even when legal
aid is available. Without a “warm hand-off” by a trusted clinician or social worker, patients
sometimes demonstrate inconsistent follow-through when referred to a lawyer for assistance
(Wilson-Hall et al., 2020). Despite this, a broadened scope of support is a move in the right
direction but offering only partial respite is tantamount to simply applying a bigger band aid on
an infectious wound. Relief may last longer, but commonly it is only a matter of time before the
presenting medical issue becomes problematic, once again. Take, for example, when a diabetes

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patient is in danger of losing housing; legal intervention can arrange for a 30-day rental
extension. However, if unaddressed mental illness is playing a role affecting their job/economic
security, a rental extension just postpones the inevitable.
A holistic healthcare approach, on the other hand, would help direct attention to other
harmful, yet treatable, conditions in patients’ lives that would increase the efficacy of medical
intervention. As the import of SDOH in minority life becomes clearer in healthcare practice, it
reveals the need to focus on the big picture, in addition to obvious health-impacting variables, to
determine appropriate diagnosis and treatment (Gottlieb et al., 2017). For this, a multi-
disciplinary approach, utilizing the specialization of social services practitioners, will be crucial
to access the roots of these issues to facilitate more effective preventive health strategies and
treatment applications (Valverde, 2017). Until then, we will continue to see the health gap
perpetuated by marginalized minorities who fall through the cracks.
Stakeholder Perspectives
There are medical practitioners aware of healthcare’s limitations who want to do more for
health gap victims but are challenged on how to do so. For instance, some electronic health
records (EHR) have social needs/SDOH questions to assess such things as homelessness,
intimate partner violence, or food scarcity (Gold et al., 2017). A prominent issue, though, is the
time constraint under which physicians work. They may understand how disruptive these
variables can be in people’s lives, however, the typical 15-minute office visit does not allow
much opportunity to complete a patient’s history. Additional issues for doctors are the distracting
environs of healthcare facilities or simply the need to focus on their job of addressing a patient’s
medical issue. Yet when doctors are able to sufficiently assess patients’ health-harming needs,

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they may not have enough knowledge about community resources to help (Garg et al., 2019;
Tames et al., 2003; Zazove et al., 2017).
Medical-Legal Partnerships are a collaborative that were formed, in part, to respond to
these issues and have performed well with social needs involving legal matters (Malik et al.,
2018; O’Sullivan et al., 2012; Sege et al., 2015). Some of these legally related needs include
unsafe housing, homelessness, wrongful termination and denial of disability payments. Usually,
these situations can be cleared with a formal letter to the responsible party sent by the legal
practitioner. As a result, there are asthmatic children living in better living conditions and
disabled individuals receiving the financial compensation they deserve. This approach was
innovative at the time of its inception and over the years has helped a number of health gap
victims. Nevertheless, medical and legal practitioners are not able to address all health-harming
social needs, therefore, they are limited to the degree they can make serious headway into health
disparities (Colvin et al., 2012) (see Appendix A for Stakeholder Map).
Implications for Targeted Population
The unfortunate intersection of discrimination and health inequities does not merely
influence lives of individuals but sends harmful ripple effects throughout communities and entire
generations. Specifically, minorities are not only afflicted by racism on a daily basis, but the
lives they are born into are marginalized from years of racial prejudice that affected their parents,
their parent’s parents, and so on (Bailey et al., 2021; Gibbons, 2008; Hammonds & Reverby,
2019). In this manner, the health of Black persons is not only compromised indirectly by the
circumstances they are born into, a crucial determinant of health, but also directly by the chronic
stress from racism they are exposed to every day - a legacy, unfortunately, they will likely pass
down to their offspring (Forde et al., 2019; Marchildon, 2020). It is these trickle-down effects of

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racial and health inequities that perpetuate a cycle of minorities born into families and
communities already disadvantaged and marginalized.
Like most dysfunctional relationships, the one between racism and health disparities is
complex and from it stems problems just as complicated. To successfully dismantle the
aggregate pieces comprising this exponentially wicked duo requires not only a deep, holistic
perspective to recognize their paired dynamic but their individual components, as well. Social
workers, with their systems perspectives and expertise in formative relationships, are perfectly
primed to be significant additions to multi-disciplinary teams in tackling these Grand Challenges
and their conjoined effects.

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Solution Landscape
There are a plethora of health gap initiatives that have proven effective in helping
individual minorities living in poverty so in this respect many of them are successful in their
mission. Nevertheless, the U.S. health disparity problem is as pervasive as before (Brown et al.,
2019; Papanicolas et al., 2018). Partnerships such as MLPs can accomplish more, but clearly
there is more work to be done. With the complicated, complex nature of health inequities, we
must think bigger regarding innovative ways to get serious traction in reducing the health gap,
and by extension, problems stemming from racism, as well.
A SWML Partnership goes beyond traditional collaborative efforts by creating teams able
to enlarge their focus on the array of individuals’ health-harming factors, but also enlarge their
scope of improvements to encompass whole communities and populations. For example, in the
immediacy, it could help health gap victims get off the punishing merry-go-round of medical
racism to establish functional, healthier patterns in their lives, and thus, their family and social
circle, as well. Positive change could be enacted on mezzo levels as social workers help direct
the partnership’s focus on whole communities with broader needs, such as food scarcity. Social
workers could also help enhance macro efforts on determinants even further upstream by
working alongside SWMLP lawyers to address global issues like policies driven by long-term
structural racism.

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Conceptual/Theoretical Landscape
In today’s complex and interconnected world made up of intricate, intersecting factors, it
will take this gestalt approach to make inroads into health disparities and racist norms. The
concept behind Systems Theory offers the very framework from which to do so (Meadows,
2008). More specifically, this type of comprehensive thinking depicts society as a complex
network, where varying factors affect and are affected by each other. It is the roots and
interactions that make up this system and reveals how the damaging phenomena of social
disparities and racism are perpetuated across different sectors like healthcare, housing, job
security and financial status. Yet, too often we approach medical treatment with a mind-set that
once grown, an adult’s mental, psychological and physical states are fixed in time, so generic,
singularly focused remedies abound. However, the concept that people’s entirety is an entity
comprised of a subset of smaller systems needs to be universally factored into healthcare’s
approach.
Social workers have highly developed skills understanding social systems, navigating
community resources, and advocating for marginalized populations. Hence, they make viable
team members specially equipped to take on racist-driven health inequities. For individual
assistance, social workers provide the culturally competent and trauma-informed care patients
need to overcome their personal barriers. By extension, social workers help lift up and amplify
disenfranchised communities, helping to heal the system in which its members live. Through
community outreach and education, social workers can raise awareness about social disparities
and racism, fostering a more informed and inclusive society. They are able to advance even
larger systematic change by helping develop targeted interventions and policy recommendations
that address over-arching issues, such as poverty, housing and food insecurity.

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Integrating social work into MLPs will help harness this power of systems thinking into
practice by elevating medical care to enlarge its scope of cause, diagnoses and treatment to
accommodate peripheral factors behind ill-health and assist legal interventions to align with
broader social goals. This holistic strategy, then, could lead to transformative change at both the
individual and community levels. Consequently, through collaboration, advocacy, and policy
change, social workers, healthcare providers, and legal professionals can forge a path toward a
more equitable and just society for all.

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Methodology
This research was conducted using a Human Centered Design approach utilizing these
steps.
Identify an Opportunity
A holistic method is the most effective healthcare approach for any patient, especially
impoverished minorities plagued with many external health-harming variables. Assisting with
these needs promotes equity and enables Black individuals to increase health outcomes and
agency; something imperative to social justice, social work’s primary aim.
Scope of Project
The goal of enhancing MLP operations with social work inclusion is ambitious, but the
wealth of research available in NCMLP materials was central in informing what adjustments are
necessary and how to accomplish them. Input from key NCMLP and MLP players was highly
beneficial, as well. These extensive NCMLP resources provided an excellent framework to build
upon for advancing social work utilization within MLPs so to better address racist driven health
disparities.
Design Brief
In the design brief that helped map the planning process, key points are outlined that
served as the basis for the Capstone project’s focus, namely how is it that current health gap
interventions can be successful for individuals, but not for decreasing health disparities, overall?
(see Appendix B).
Research and Key Takeaways
One-on-one research opportunities yielded various insights with respect to experiences
and perspectives concerning racism, disparate health outcomes, and medical care. Ethnographic

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and qualitative research was also used to glean data from NCMLP and National Minority Quality
Forum (NMQF) conferences and online events.
Key takeaways include: 1) medical care access alone is not the issue, 2) NCMLP/MLP
programs recognize social work’s potential and know they need to expand collaborations for
more effective practices, but there is no clear path how to formally incorporate social work into
MLP operations, and 3) broadening partnerships makes for more complex functioning, a barrier
to increased collaboration (see Appendix C for further details).
Design Criteria
To formulate the design criteria, necessary goals and barriers to successful
implementation were considered for the framework guiding the development of this initiative
(see Appendix D).
Brainstorm Ideas
NCMLP’s 77-page MLP implementation toolkit served as a baseline to mine ways social
work’s impact could be utilized to maximize MLP practices. This yielded approximately 87
opportunities for social work enhancements (Marple et al., 2020).
Develop Concepts
Callout boxes, with descriptive points, were created to highlight each of these 87
opportunities in NCMLP’s toolkit (see Appendix E for example). MLP design partners and
medical social workers helped cull the most crucial of these to create an outline for an instructive
curriculum guiding social work integration. Further assistance illuminated how to conceptually
break them up into coherent groups to be addressed in learning collaborative sessions.
Prototype
(click HERE for full prototype)

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The final prototype, an online learning collaborative to advance a SWMLP approach, is
comprised of suggestions summing up salient issues derived from the design thinking process.
These major points fall into three main categories with each covered weekly. NCMLP staff will
facilitate launching this free collaborative, disseminate on their website, and assist with future
iterations and scalability. Many available resources include class materials, a SWMLP YouTube
channel, a SWMLP website, and an online discussion forum. To augment the learning process,
breakout groups will allow for deeper conceptual integration and sharing of ideas (Holding,
2023).
Plans for Stakeholder Involvement
Stakeholders, from various ethnic backgrounds and professions, provided vital input for
the basis of scholarly inquiry into racism and health disparities as well as guide direction for
continued research. These individuals included medical practitioners, medical social workers,
hospital executives, MLP lawyers, MLP experienced social workers, and legal practitioners
interested in starting an MLP practice.
When working on innovative solutions, NCMLP stakeholders and fellow MLP learning
collaborative participants helped illuminate specific elements to consider in a functional health
equity intervention and a successful pilot. As committed stakeholders, they will continue to help
guide the prototype testing process and eventual scalability of a SWMLP intervention.
Communication Products and Strategies
The SWMLP learning collaborative offers many communication venues throughout its
duration and beyond. The interactive design allows two-way communication between
participants and panelists as well as breakout rooms for small group discussion. Attendees will
also receive corresponding handouts/worksheets each week, pertinent links, and access to all

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PowerPoint slides and session recordings. SWMLP’s website and the SWMLP discussion forum
will be made available, as well.

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Proposed Solution
This Capstone innovation was designed to assist Medical-Legal Partnerships in
enhancing operations by formally incorporating a social work leader. When the prototype was
near completion, it was sent to NCMLP co-director, Bethany Hamilton, an instrumental source
of early research, for feedback and possible support. Ms. Hamilton endorsed the learning
collaborative to be hosted on NCMLP’s platform this Fall 2023 with plans to disseminate its
launch by featuring it on their website’s “Learning Opportunities” page (https://medical-
legalpartnership.org/learning-opportunities/) and via their monthly email newsletter.
Theory of Change
To increase physical well-being among disenfranchised minorities, the solution is not a
simple equation of presenting health problems + medical intervention = positive patient
outcomes. Within individuals, our body parts work in a systematic way; the same applies for
how we function in our lives, families, communities, and greater society, and within their
intersections. Therefore, adjusting one variable does not necessarily lead to a singular, direct
linear effect on another. Hence, if all of life’s aspects playing a role in patient health are not
considered, the ‘revolving door’ for super-utilizers will remain in place. Minorities’ health, then,
will continue to cycle leading to compromised upward mobility, constancy of racist tropes,
marginalized communities - all which keep Black populations disadvantaged for social
advancement and equity.
Systems theory posits a multifactorial, multi-tiered approach, one of the most effective
solutions to create desired, enduring changes. Therefore, this is the likely method that can help
decrease health disparities and improve overall health outcomes for people of color and their
communities. The change theory demonstrates how broad issues of racism and health inequities

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can be broken down into the smaller subsets of factors leading up to them and the change
variables to disrupt this flow (see Appendix F for Theory of Change). The logic model depicts
how a systems approach can be used to address the whole of the racial disparities problem to
create outcomes reflecting a healthier system and its more functional components (see Appendix
G).
Prototype Description
The training curriculum provides MLPs with social work implementation techniques and
will be taught through an online learning collaborative, “Revolutionize Your Medical-Legal
Partnership: Introducing the SWMLP (Social Work-Medical-Legal Partnership).” This
educational opportunity will be broken up into three one-and-a-half-hour weekly sessions. A
number of resources are available for attendees, including corresponding weekly worksheets,
recordings and slides from all three sessions, and useful links listed on the SWMLP website
(http://swmlpartnership.com/). Each session will feature an experienced panel to provide their
skill and ‘know-how’ that relate to particular session topics followed by a Q&A session.
At collaborative’s end, attendees will be offered the opportunity to join an online
“Developing a SWML Partnership” peer info exchange type of forum to allow for questions,
suggestions and ideas to share with others in an online Google discussion group. A continuing
discussion board of this nature will allow the chance to learn from others’ experiences and may
facilitate continuity of practices and standardization as partnerships adopt shared SWMLP
techniques, an issue NCMLP needs to address (Girard et al., 2023; Regenstein et al., 2017). An
ongoing SWMLP discussion group may also be mutually advantageous as it could provide real-
time feedback regarding the learning collaborative’s success as well as insights for helpful
iterations.

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Session one, “Initial Phase: Social Work Integration”, will focus on the first stage of
bringing social work on board and necessary accommodations in partnerships’ operating
procedures and record-keeping. For example, a common mistake of new MLPs is not thoroughly
understanding the community they are serving ("The medical-legal partnership toolkit: Laying
the groundwork," 2015) so it is recommended an in-depth community landscape analysis,
conducted by the new SWMLP social worker, is the first order of business. The subsequent
results, combined with the clinic’s increased social work capabilities, may change what
SDOH/social needs are prominent. Therefore, all three practitioners - doctors, lawyers, and
social workers – will need to agree what their partnership’s focus will be and possibly
redetermine achievable outcomes for their practice. Another example of covered material in
session one concerns patient privacy and confidentiality. It is imperative all clinicians come to a
consensus regarding what information will be shared and how it will be communicated, then
patient confidentiality forms will need to be updated accordingly. For convenience, blank
templates will be made available to learning collaborative participants.
Session two, “Operations Phase: Adjusted Workflow”, entails optimal ways to
accommodate how a SWMLP will work differently than an MLP by a rearranged workflow that
will ideally increase efficiency and enhance patient success. Studies of healthcare based social
work suggest a deeper, more thorough SDOH assessment is associated with increasing positive
patient outcomes (Craig et al., 2015). Subsequently, a suggested modification at this stage is that
social work conduct all intake evaluations to provide a more complete appraisal of patient
functioning. Another recommendation to leverage the benefits of a dedicated social worker is the
possible impact on new community partnerships and referral opportunities. Therefore, social
work should coordinate outreach and provide in-services to potential parties in other medical

26
settings and the wider community as a way of introducing SWMLP’s enhanced capabilities.
Other benefits to an on-site social worker include the ready availability of mental/emotional
health services. It has been noted when a healthcare team lacks social work expertise, providing
an outside referral for counseling may not be as effective among certain populations if there is
stigma attached to these services (Salcedo, 2023). Having these resources “in-house” will likely
encourage patients to follow-through with necessary mental health treatment needs.
Session 3: “Duration Phase: Ongoing Considerations” covers tasks to optimize clinic
functioning and periodic issues to be addressed during the normal course of business operations.
For instance, much of the recent emphasis on health equity concerns the role of SDOH, subjects
with which social workers are very well acquainted. With a clear commitment to supporting
social work’s healthcare contributions, a SWML Partnership may find new social service grants
and non-profit support more accessible, so this funding base should be investigated. For
example, the Center for Disease Control and Prevention (CDC) is just one of the organizations
offering new venues of financial support to SDOH initiatives ("CDC announces grants to address
social determinants of health," 2023). Another continuing benefit of social work inclusion is the
value a social work leader brings to interdisciplinary training. Social workers, medical
practitioners, and lawyers have expertise in their own practices and possess knowledge that could
benefit each other’s work and by extension, SWMLP operations. An illustration is how social
work’s enriched knowledge of SDOH could increase doctors’ and lawyers’ understanding of
these variables and their dynamics.
Contributions to Grand Challenges
The Grand Challenges of Social Work are well-named in that the problems fueling them
are complex with far-reaching, damaging effects. Close the Health Gap and Eliminate Racism

27
are two examples and are catastrophic enough on their own although they frequently work in
tandem, compounding their devastation in multiple ways. As a result, discrimination and health
imparity create racist cycles difficult to disrupt as these societal ills reinforce each other in
minority’s lives, and by extension their communities, as well.
Smaller-scale assistance is fundamental and must continue, but a more efficient and
global approach is necessary to dismantle the Grand Challenges heavyweights of racism and
health disparities. To wit, arranged housing for a heart disease patient is inefficient without
intervention for their psychiatric disorder that may contribute to their homelessness. A
recovering addict is more likely to remain healthy and maintain full-time employment with
recovery support. Educational opportunities can empower victims recuperating from intimate
partner violence and help with career goals to increase their independence. It is these more
inclusive methods that can enable such individuals to escape the punishing merry-go-round that
serves to perpetuate unfair and discriminatory stereotypes.
Likelihood of Success
Given our current mores, it is an opportune time for an initiative that endorses a holistic
approach to U.S. health disparity. The Covid 19 pandemic brought health inequities into sharp
focus illuminating the degree to which the health gap is pervasive and damaging (Moore et al.,
2022). Additionally, upstream determinants, SDOH, are a current focus of studies and research
discloses how their effects on social needs and health are more evident for those on the low end
of SES, most of whom are people of color (Bailey et al., 2021). This type of clarity reveals how
the complicated, over-arching problems that cause, and are caused by poor health, require a
global response to make serious in-roads into health inequities. For this, we need to build on past

28
knowledge and interventions for up-to-date techniques to tackle health disparities made all the
more complex in modern society.

29
Implementation Plan
As a crucial stakeholder, NCMLP is invested in the concept of having social work
leaders at the table with Medical/Legal and has been an important resource informing the
creation of the SWMLP learning collaborative. As such, Ms. Hamilton, the national co-director,
is committed to having NCMLP partner with this intervention to disseminate this opportunity as
well as making it available on their platform this Fall (date TBD). Peripheral MLP stakeholders,
such as, program directors, clinicians, and personnel, as well as other interested parties, can sign
up on NCMLP’s website. There will be a minimum of 5 attendees for the pilot launch but with a
maximum of 25 enrolled overall.
Administrative details associated with hosting an online learning collaborative – available
dates, list of signees, zoom invitations, session materials – will be managed through NCMLP
offices. In the occasion a wait list is needed, NCMLP’s digital platform provides the possibility
of hosting additional learning collaboratives. A successful pilot of the SWMLP learning
collaborative may indicate it could, with potential funding, become a recurring educational tool
for NCMLP.
The National Association for Social Workers (NASW), as pivotal stakeholders in
expanding social work leadership, is offering the opportunity to publicize the SWMLP learning
collaborative in this author’s upcoming blog featured in the Health Practice Tools section of their
website (https://www.socialworkers.org/Practice/Health/Health-Tools). NASW also hosts an all-
member forum, emailed daily, where its launch can be announced on a medium that allows
social work stakeholders, nationwide, to reach out for additional information.

30
Market Analysis
Medical-Legal Partnerships exist in 49 states, District of Columbia, Canada and
Australia, and assist more than 75,000 individuals each year, much of which involves helping
individuals recover nearly $170,000 annually in back benefits. It is typically reported the value
clinicians find in MLP services are reflected in:
• 86% reporting improved outcomes for patients
• 64% reporting improved compliance with treatment regiments
• 385 reporting that it allows them to perform “at the top level of their licensure.”
Specifically, Medical-Legal Partnerships have been integrated into approximately 450
healthcare organizations including:
• 138 - General Hospitals / Health Systems
• 37 – Children’s Hospitals
• 163 – HRSA-Funded Health Centers
• 83 – Other Healthcare Sites
• 29 – Veterans Affairs Medical Centers
("International medical-legal partnerships," 2016; National Center for Medical-Legal
Partnership, 2023). A complete list of the names and addresses of U.S. MLPs is accessible
through the American Bar Association website at:
https://www.americanbar.org/groups/probono_public_service/projects_awards/medical_legal_pa
rtnerships_pro_bono_project/directory_of_programs/
Line-Item Budget
A simple line-item budget was created to highlight the cost of implementing the learning
collaborative and reflects the utility of the Zoom platform as a cost-neutral venture, in large part

31
due to the in-kind generosity of NCMLP offering their webinar platform, expertise and
assistance. Finally, time spent preparing and executing the learning collaborative will also be in-
kind and the line-item budget below reflects these specifics. After a successful launch and
necessary iterations, private donors have pledged approximately $10,000 to assist further
marketing and operations to sustain the SWMLP learning collaboration’s availability to future
participants.
Figure 1

Line-Item Budget for initial SWMLP learning Collaborative
Methods for Assessment
When assessing a design thinking project three important concepts are Desirability,
Feasibility and Viability (UXPin, 2023). An initial indicator of desirability will be how many
people sign up for the learning collaborative on NCMLP’s website when it becomes available.
After collaborative’s end, participants’ satisfaction can be gleaned from NCMLP’s survey which
will provide important data regarding future iterations; a standard metric utilized with their
online educational opportunities. This is done with a link to a Survey Monkey questionnaire
provided to participants upon completing an MLP webinar/learning collaborative and includes
questions, such as, “How well did this event meet its stated objectives?” and “How confident are
you that you will be able to apply information you have received today at your health
center/program/organization?” (https://www.surveymonkey.com/r/XKDLZT6). A sample

32
NCMLP survey from the collaborative, "Developing a framework to sustain your MLP”, is
depicted in Appendix H.
Particularly useful is the adaptive nature of NCMLP’s survey. To reflect the pertinent
subject matter, modifications can be made to ask more tailored questions, such as the extent
MLP participants find it feasible to implement a SWMLP. Further queries can be made regarding
achievability of any particular guideline. For example, in the first session, “Initial Social Work
Integration,” a suggestion is for SWMLPs to make use of EHRs for ease and accuracy, however
not all healthcare facilities have the means or the know-how to utilize them. Additional
qualitative measurements can be obtained from participants’ comments in the SWMLP online
discussion forum and traffic directed to the SWMLP website.
With respect to a new SWML Partnership, viability will likely depend on available funds
to cover a social worker’s salary and the miscellaneous resources involved. To assist in creating
a draft budget to reflect these changes, a simple excel will be provided as a template to help MLP
participants assess their financial means and ability to cover these costs long-term. This is
especially important from an ethical standpoint as it is crucial a SWMLP sustains functioning
once a community comes to rely on their services.
Communication Strategies
As mentioned, there are a number of ways to circulate this prototype to interested parties.
NCMLP will disseminate through their monthly email newsletter and on their website. NASW
also features advertising opportunities via a blog in the Health Practice Tools section of their
website and the NASW All Member Forum Digest where a brief description can be provided.
Further communications can be mediated through professional associations, such as
current MLPs that endorse formal social work inclusion, and contacts made at the MLP

33
conference at Yale University in March 2023. Additional promotion can be done via social
media, the SWMLP YouTube channel and a listserv blast email.

34
Challenges
Ethical Concerns and Potential Negative Consequences
As an approach and not a mandate, a SWMLP learning collaborative only offers
guidelines, not requirements; therefore, a risk is participating practitioners not adopting
important strategies. For instance, despite emphasis on clear, consistent communication, this
tactic may fall by the wayside when clinicians get busy or are lulled into a false sense of
complacency over time. It is possible the pilot launch may reveal these considerations and the
useful iterative nature of this initiative allows it to adapt accordingly to address them and other
potential obstacles that may arise.
Design Justice Principles
Design thinking shares similar principles with social justice theory, so the creation of this
Capstone project naturally aligned with their fundamental beliefs. For example, before setting
out to design a new initiative, current programs were assessed and great respect is given MLPs
and what they have accomplished. Hence, a social work addition is not meant as a replacement,
only an enhancement to broaden their capabilities. Another motivation was to heal and
strengthen those in need, thereby, assisting impoverished minorities and empowering them with
more control over their outcomes, health and otherwise. Furthermore, the SWMLP approach is
an accessible, collaborative process and not a static, finished product. In fact, a critical feature of
this intervention is its generalizability to other situations. For example, A SWMLP program
could be used in academic-based MLPs or incorporate other health specialties ("Design justice
network principles," 2018).

35
Conclusions and Implications
Concrete plans-Next Steps
At present, additional consultations are scheduled with NCMLP. Among items to be
addressed are NCMLP personnel task roles, elicit MLP professionals for expert panels, and
establish possible dates for the Fall launch of the SWMLP prototype pilot. Once the timing of the
SWMLP learning collaborative is set, it will be promoted by dissemination via multiple avenues.
Naturally, the exact date of the SWMLP collaborative sessions will be determined with regard to
numerous schedules and availability of expert panelists. Plans include bringing NCMLP and
NASW together in a joint partnership which will facilitate the promotion of the SWMLP
learning collaborative initiative, and ultimately its scalability.
What Makes This Innovative?
A crucial observation during Capstone research was the universal appreciation for the
role social services can play in alleviating health disparities and interest in elevating social
work’s involvement, yet it is underutilized. A barrier to improved strategies can be attributed to a
fundamental element of human nature: even when the old guard ceases to be as effective, people
may resist adopting novel, creative approaches, despite basis on solid data and best practices.
Ironically, previous program achievement can post certain risks to innovations, as well. When
particular gains are realized, they can create illusions of outsized success that may not represent
reality. More specifically, current health gap programs are critical for meeting individual needs
but these positive results should not be mistaken as commensurate with significant progress in
addressing health disparities, overall (Agurs-Collins et al., 2019). Fortunately, though, it appears

36
stakeholders are ready to take on more innovative approaches that will achieve next-level
advances in interventions to battle health inequity.
A variable that may partially explain the prevalent appreciation for social work’s import
is the advanced understanding of SDOH and their role in poor health outcomes for minorities.
There seems little doubt social work is not only a discipline uniquely qualified to understand
upstream social determinants and the needs they spawn downstream, but social workers also
have the particular skills to address them. Additionally, there is a growing appreciation for social
work’s place in leadership and its enhanced ability to contribute on macro-levels. Therefore, the
landscape appears ripe for placing social work guidance squarely in the forefront of health gap
research and program development. Motivated to elevate their game in the battle against health
disparities, MLPs appear open to leveraging social work expertise to enhance their patient
outcomes. The SWMLP learning collaborative will provide them a road map to do just that.
Information Sharing with Practitioners and Stakeholders
As stated in the Implementation section, there are a multitude of dissemination
opportunities on multiple platforms involving professional organizations, a SWMLP YouTube
channel, a listserv blast email, and social media, such as, Facebook, Instagram and Twitter.
Project Implications
In conclusion, an important feature of the SWMLP collaborative is the potential for
multi-level contributions in the fight for health parity. Firstly, promoting social work inclusion
can help an MLP broaden its goals, increase patient services, encourage efficiency, and improve
overall patient outcomes. Secondly, social workers can enact mezzo-level benefits to improve
communities-at-large by forming social needs focused interventions. Thirdly, social work can

37
also benefit macro-level changes with specifically informed policy amendments and programs to
disrupt structural racism. However, the beauty in this initiative is how, like racism and health
disparities, it can be self-reinforcing, but in the best possible way.

38
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Appendix A
Stakeholder Map

48
Appendix B
Design Brief

49
Appendix C
Research & Key Takeaways

50

51
Appendix D
Design Criteria

52
Appendix E
Breakout box: how legal and social work can help address IPV victims’ needs

53
Appendix F
SWMLP Theory of Change

54
Appendix G
SWMLP Logic Model

55
Appendix H
NCMLP Sample Survey

Abstract (if available)

Abstract The persistent challenge of U.S. health disparities remains despite extensive research and various efforts to address the issue, complicated by health harming social needs fueled by broader, upstream determinants of health. While specific wellness initiatives and smaller collaboratives offer some relief and mezzo-level solutions, a multi-dimensional strategy with the expertise of key professionals is needed to make true progress. The Medical-Legal Partnership (MLP) approach which uses lawyers to address patients’ legally based social needs has shown promise but has limitations in effectively addressing other damaging social needs. Social workers, with their clinical skills and understanding of community members, can greatly enhance MLP operations, but are often underutilized. Hence, by incorporating social work as leaders alongside doctors and lawyers, MLPs can become suitably comprehensive to elevate their impact at multiple levels. To address this, a guideline for integrating social work leadership into MLPs, called the Social Work-Medical-Legal Partnership (SWMLP), has been developed. The SWML guideline curriculum, available on the National Center for Medical-Legal Partnership's (NCMLP) platform, provides a structured online learning collaborative broken down into three weekly segments that focus on incorporating social work's role and adjusting workflows. This holistic approach aims to save time and costs in treatment while achieving positive patient outcomes. It also has the potential to maximize mezzo and macro-level impacts by enhancing community projects and policy change with social work’s expertise informing these efforts. In addition, this approach may help address the broader, upstream determinants of health that complicate health disparities.

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Asset Metadata

Creator Holding, Margaret Hawkins (author)

Core Title The social work-medical-legal partnership: next-level collaborating

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2023-08

Publication Date 08/09/2023

Defense Date 07/31/2023

Publisher University of Southern California. Libraries (digital)

Tag design thinking,grand challenges,health disparities,health equity,health gap,health inequities,health outcomes,learning collaborative,Medical care,medical legal partnership,OAI-PMH Harvest,racism and health,social determinants,social needs,social work,social worker,swmlp

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Rank, Michael (committee chair), Hatley, Todd (committee member), Wiley, June (committee member)

Creator Email holdingb@usc.edu,mhawkinsholding@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113297979

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Rights Holding, Margaret Hawkins

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