Barriers to Implementing Medical-Legal Partnerships for Survivors of Intimate Partner Violence: Qualitative Perspectives from the Veterans Health Administration.

Abstract

Intimate partner violence (IPV) is associated with adverse social determinants of health, including housing instability, financial insecurity, and legal problems that negatively affect health. Medical-legal partnerships (MLPs), in which legal practitioners are embedded in healthcare settings to address civil legal needs (e.g., eviction), are an evidence-based strategy to mitigate associated harms. However, little is known about MLP implementation for patients experiencing IPV. To identify implementation barriers and facilitators influencing delivery of MLP services within the Veterans Health Administration (VHA) for patients experiencing IPV. Qualitative, multi-site study using semi-structured interviews and ethnographic document analysis. Twenty-five VHA clinical staff, including clinicians, social workers, and other frontline team members involved in MLP referrals and care coordination for patients experiencing IPV. Interviews explored current MLP practices, implementation outcomes, and barriers and facilitators to MLP implementation for patients experiencing IPV. Participants were asked to share documents used in MLP implementation. Data collection and analysis were guided by the revised Consolidated Framework for Implementation Research. We identified five cross-cutting factors shaping MLP implementation for IPV survivors: (1) disruptions related to COVID-19, (2) MLP's organizational home, (3) concerns about liability, (4) limited knowledge of legal services and referral processes, and (5) uncertainty of MLP value. While many barriers reflected outer setting conditions that may be challenging to address, several modifiable factors were identified as targets for improvement. Despite challenging funding conditions, findings point to opportunities for improving MLP implementation and reach to better address civil legal needs among veterans experiencing IPV. Targeted efforts to relocate MLP services in clinically appropriate program homes, reduce intermediary steps in the referral chain, and close gaps in clinician awareness may enhance access for patient-survivors. Findings can inform scalable approaches to embedding civil legal assistance within clinical settings. Not applicable.