By Stacey Kusterbeck
Many unmet social needs are the true underlying reason for ED visits, although they often go unrecognized at the time of presentation, warns Danielle Cullen, MD, MPH, MSHP, an attending physician in the ED and a social care researcher at Children’s Hospital of Philadelphia. Cullen offers these examples:
- Patients with food insecurity may present with abdominal pain, headaches, or intolerance of medication. Due to concerns regarding stigma or fear of negative repercussions, such as involving child protective services, patients may be reluctant to acknowledge food insecurity.
- Seizures in infants can occur because parents make the dangerous decision of watering down formula to make it last. This can create electrolyte changes like low sodium that may cause seizures, says Cullen.
- Patients with utility insecurity may present with asthma exacerbations because they cannot use a nebulizer for breathing treatment. The inability to treat asthma effectively at home leads to frequent ED visits. Utility insecurity also can create safety issues for patients who rely on ventilators and tube feeds. “If electricity is turned off, they wouldn’t be able to use the devices that they depend on to breathe and eat, necessitating hospital care,” says Cullen.
- Patients living in poor housing conditions may present to EDs with asthma exacerbations. Patients can have a harder time controlling asthma symptoms, despite receiving more medications, because of allergens produced by cockroaches or rodents.
- Patients may be experiencing interpersonal violence and homelessness, creating immediate safety issues. If ED providers don’t know about the dire situation, the patient could be discharged to the streets or an unsafe home.
“Often, under-resourced families have difficulty accessing primary care, making the ED a uniquely poised site of potential intervention,” says Cullen. During wait times, ED providers can offer to connect patients with resources in a way that facilitates privacy and maintains dignity. Cullen suggests:
- ED providers can bring up the topic of social needs in a matter-of-fact way, and then offer some helpful resources. “Normalize the fact that times are stressful and that many families are facing challenges,” recommends Cullen.
- ED providers can have the conversation in the privacy of an exam room and ensure that patients will not have to disclose their struggles in front of their children.
- ED providers can offer resources to any patients who desire them, regardless of screening results. For example, if someone screens negative for food insecurity, that patient still should be offered resources if desired.
- EDs can partner with social workers and community-based organizations to develop a referral process or a trusted short-list of geographically appropriate services.
Before asking questions about social needs, EDs first have to identify resources to offer. “In my mind, the ED is a natural setting for this,” says Cullen. EDs can facilitate handoffs to social workers or community agencies to meet urgent needs (such as having no food, interpersonal violence, or no safe place to sleep). “If a social need is at the core of a visit or would be a barrier to resolution of the presenting complaint as described previously, then our failure to address this issue would be a failure to provide effective care,” emphasizes Cullen.
Kerry Cahill, JD, an attorney at Lindabury in Westfield, NJ, has seen these patient safety implications for ED patients with health-related social needs:
- medication errors;
- incomplete charts;
- inadequate continuity of care.
“During a patient’s visit, screening for social needs can help ED providers recognize what treatment would be most successful and beneficial for a patient,” says Cahill.
Without screening for social needs, Cahill says that ED patients may face physical, psychological, and economic consequences. Patients’ health can deteriorate; they may need more intensive or invasive treatment; they may have poor behavioral health outcomes; and they may be unable to provide dependent care. Once ED providers make health-related social needs a part of the assessment, they may notice some of these issues. Some patients’ conditions may be related to failing to take medications that are unaffordable or to poor dietary choices caused by a lack of healthy food options. Ideally, EDs are connecting those people to community resources. “Additionally, these efforts have significant benefit for the ED, in terms of lower malpractice claims and decreased litigation exposure,” says Cahill.
Discharge requests like “Rest, elevate and ice the area,” “Drink lots of fluids and stay out of heat,” or “Keep bandages clean, dry, and intact for two days” sound simple. However, such instructions may be unattainable for individuals affected by social determinants of health. “At the outset, this puts these patients at a distinct disadvantage to receiving equitable care from the ED,” says Heather L. Brown, DMSc, PA-C, a Roswell, GA-based medical-legal consultant.
Some ED providers do screen for health-related social needs. “But first, it’s important to try and remove our own biases in the process,” says Brown. An ED nurse may ask about “safety at home,” for example. Not all ED patients have a stable home environment and feel safe. “Not inquiring about all the issues that may confound a patient’s care once they leave the ED is a common but costly omission,” says Brown. It’s impossible to anticipate all the needs of every ED patient. However, ED providers can start by asking patients if they see any barriers to compliance with the care plan.
“Don’t make it the patient’s sole responsibility to ask for help. Make it the provider’s commitment to treat the whole person in front of them, taking all aspects of their health into account,” urges Brown. Some patients are unable to afford costly medications. ED providers can come up with an alternative medication regimen, provide samples of the medication, or arrange for the patient to get a drug discount program through the manufacturer. Such efforts can prevent the patient from having a poor outcome. “Return visits to the ED, often for what has become a more complicated problem, is an avoidable problem for patients with health-related social needs,” warns Brown. Overall, ED providers must be willing to work with patients to find a treatment plan that meets best practices, but still is an attainable goal for the patient. “The best-laid plans won’t work for a patient who can’t afford them, or access them, or be consistent about doing them,” observes Brown.
Many unmet social needs are the true underlying reason for ED visits, although they often go unrecognized at the time of presentation. Without screening for social needs, ED patients may face physical, psychological, and economic consequences.
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