Strategies to Integrate the Practice of Social Emergency Medicine Into Routine Patient Care

R.B. IS A 32-YEAR-OLD African American, female patient who has recently relocated to town and presents to the emergency department (ED) in the early afternoon with a chief complaint of “I need my Eliquis for the blood clot in my leg.” She states that yesterday she was evaluated at another ED for left leg pain and swelling and was eventually diagnosed with a deep vein thrombosis (DVT). She denies any injury or trauma, chest pain, or dyspnea. R.B. states that she noticed the leg pain and swelling a week following a 2-day road trip she took to relocate to begin her new job. She has been unemployed for the past year and recently was able to obtain a job in a local call center with the help of her friend who lives in town. She denies any medical history or chronic illnesses. R.B. shares with the nurse practitioner (NP) that she has been on an oral contraceptive (Junel 1/Fe) for the past 5 years and that she is not taking any other medications. She is single and lives alone.

Physical examination reveals vitals: temperature 37.4 °C, heart rate 92, blood pressure 125/76, respirations 18, and a pulse oxygen saturation of 100%. She is well appearing, in no acute distress, and is ambulatory with an antalgic gait. She appears well groomed and is calm but slightly anxious. Bilateral lung fields are clear to auscultation, and respirations are unlabored. Auscultation of her heart reveals S1 and S2 with a regular rhythm, without murmurs or gallops. Her left lower extremity skin is warm to touch, slightly erythematous at the calf with notable swelling. Bilateral femoral, popliteal, and dorsalis pedis pulses are 2+ and equal.

The NP was able to obtain ultrasound results from the ED where R.B. was initially evaluated. Laboratory examinations were repeated to rule out cellulitis and evaluate her renal function. Her laboratory tests revealed a normal complete blood count indicating no infection and her complete metabolic panel showed normal electrolytes and renal function. The venous ultrasound report of her left lower extremity revealed a nonocclusive deep venous thrombosis within the left popliteal vein. The NP confirms with R.B. a diagnosis of left lower extremity DVT and that she needs anticoagulant therapy. R.B. replies to the NP that she was given a dose of Eliquis yesterday during her visit at the other ED and showed the NP the prescription for Eliquis that she received at her discharge. She then admitted to the NP “I can't afford this medication, it's too expensive. Can you just give me another dose here in the ED?”

REVIEW OF THE ARTICLE

Wallace, Andrea S., et al. “Implementing a Social Determinants Screening and Referral Infrastructure during Routine Emergency Department Visits, Utah, 2017–2018.” Preventing Chronic Disease, vol. 17, 2020, https://doi.org/10.5888/pcd17.190339.

STUDY PURPOSE, DESIGNS, AND METHODS

The purpose of Wallace et al.'s (2020) study was to create and evaluate an innovative screening process to identify social needs/risks as part of the ED evaluation and to coordinate linkage to community-based resources upon discharge from the ED. The study was conducted at a large academic ED in Utah that serves 50,000 patients annually and was designed as a 2-phase, mixed-methods feasibility investigation. The ED was already equipped with an established care management team composed of clinical nurses and social workers responsible for coordinating care transitions for ED patients upon admission or discharge (Wallace et al., 2020). The authors acknowledged that a gap existed with understanding the impact of social determinants of health (SDOH) for patients discharged from the ED into the community (Wallace et al., 2020).

A multidisciplinary team approach that included physicians, nursing staff, and social workers was created to facilitate the selection of an SDOH screening tool and develop an ED workflow to incorporate the utilization of the screening tool as well as a referral process to community-based resources. The workgroup utilized assistance from the United Way of Salt Lake City's 2-1-1- service to provide resources for social needs in the areas of housing and utilities, food, transportation, legal, mental health and addiction, medical, dental and vision insurance, employment, education and domestic violence abuse (Wallace et al., 2020). In order to select and develop an SDOH screening tool for the ED, the workgroup reviewed existing assessment tools and questions used by nonprofit referral organizations and payors (Wallace et al., 2020). Additionally, criteria were created to assist with the selection of a screening tool. Once the screening tool was selected, it was adapted by the workgroup to reflect ED patients' needs. Screening tool questions were revised to assess patient experiences over the past year and written at a fifth-grade reading level in both Spanish and English (Wallace et al., 2020).

It was decided by the workgroup that the best point to implement the screening tool was during the earliest point of contact during the patient's visit (Wallace et al., 2020). Thus, registration staff were assigned to administer the screening tool during the initial patient registration process. However, eventually the tool was self-administered by patients. A series of four, 1-week pilot tests were implemented to evaluate the integration of the screening tool within the ED workflow with linkage to the referral system for patients discharged from the ED (Wallace et al., 2020).

An electronic portal via Research Electronic Data Capture (REDCap) was created to facilitate direct referrals to community resources (Wallace et al., 2020). REDCap was utilized to export screening tool results to the 2-1-1 community resource system. Health Insurance Portability and Accountability Act (HIPAA)-complaint data were captured and stored in the REDCap-secured web-based data warehouse. This allowed for follow-up for social needs to be completed by a designated information specialist via telephone (or text message) within 48 hr of ED assessments (Wallace et al., 2020). Optional 1-week follow-up calls were made to patients after the initial 2-1-1 contact to establish whether goals for community-based resources had been met.

DATA ANALYSIS AND RESULTS

The four pilots were conducted during the months of November 2017, December 2017, May 2018, and July 2018. The initial sample consisted of 210 patients. Initially, the screening questions were implemented via paper and pen but, during the last phase of the study, the SDOH screening tool was initiated using an electronic touchscreen. The touchscreen tool took an average of 80 s to complete (Wallace et al., 2020).

A total of 129 (61.4%) patients responded to the screening questions that they had one or more social needs within the past year. The most common social needs identified on the screening tool were patients not having enough money for items such as clothing or furniture (35.7%) and food (32.9%) (Wallace et al., 2020). Least common were reports of childcare or elder care service issues that prevented patients from getting to work or appointments (12.9%). Of the 129 patients with one or more stated needs, 73 (56.6%) asked for referral to 2-1-1 resources and 32 (43.8%) were reached by 2-1-1 within 1 week of ED discharge (Wallace et al., 2020). Patients contacted by 2-1-1 information specialists received an average of four service referrals. Most patients were referred for health services such as community clinics, prescription drug discounts, and charities covering costs of medical tests.

Wilcoxon signed rank tests were used to compare service usage 3 months before versus 3 months after ED index dates due to the small sample sizes and nonnormal data distributions (Wallace et al., 2020). Comparisons included patients who expressed at least one need (n = 107) and patients with no reported needs (n = 55), patients whom 2-1-1 attempted to contact and those who received 2-1-1 services (n = 32), and those who did not receive 2-1-1 services (n = 33) (Wallace et al., 2020). Patients who reported one or more social needs tended to have an increase in ED utilization (1.07 before vs. 1.36 after, p = 0.03) whereas patients with no needs had an increase in primary care visits (0.24 before vs. 0.56 after, p = 0.03) (Wallace et al., 2020). Increased ED visits were also noted among those who received referrals from United Way of Salt Lake City's 2-1-1 (1.97 before vs. 2.56 after, p = 0.006) (Wallace et al., 2020).

STRENGTHS, LIMITATIONS, DISCUSSION, AND CONCLUSION

The process of integrating a social needs screening tool and a referral process to community-based resources created a partnership between ED clinicians and existing community-based resource providers. Patients with identified social needs tended to utilize the ED more than those without needs (Wallace et al., 2020). Additionally, patients with social needs who were referred to community resources tended to utilize the ED more than those without social needs or those who do not receive community referrals. This reinforces the concept that SDOH closely impact the patient's acute ED visit and thereafter (Wallace et al., 2020).

Despite the developed partnership between the ED and community organizations, this study does present with limitations. For example, given this was a feasibility study, the sample size is not large. Generalization and replication of this study is possible; however, it may be limited to those EDs with well-integrated and established case management support teams with community partnerships (Wallace et al., 2020). Existing EDs that lack this type of infrastructure may be challenged if trying to replicate this screening and referral process. Staff feedback regarding the patient screening process revealed that patients with insurance or a well-groomed personal appearance were not given the SDOH screening tool by registration (Wallace et al., 2020). This selection bias by registration staff is a limitation and may reflect implicit bias. Additionally, some staff expressed discomfort asking questions from the screening tool that they felt were stigmatizing (Wallace et al., 2020). At the time of the study, no SDOH screening tools specifically developed for the ED that had been rigorously evaluated in terms of psychometrics were available (Wallace et al., 2020). Thus, the final selected screening tool was adapted for ED use but lacked psychometric validity and reliability.

The strength of this study demonstrated the need for universal SDOH screening on all ED patients to better ensure cost-effective resource use and improved patient outcomes. Additionally, it highlighted the gap that exists with staff training and competence in the areas of patient communication techniques and understanding of how implicit bias may interfere with identifying patient needs and identifying resources to improve use of care resources that may reduce unnecessary ED visits and costs of care.

AUTHOR'S COMMENTS

The ED presents a unique frontline for clinicians who care for vulnerable patients requiring attention for both medical and social needs. To effectively address a patient's medical needs, we must understand, assess, and address SDOH for all patients. The practice of integrating all aspects of SDOH is the fundamental nature of social emergency medicine (Anderson et al., 2016). By exploring the complex nature of the health care system and its intricate network within the economic and political realms, we can develop an understanding of the impact SDOH have on patients and their quality of life.

Health equity exists when all people have available resources and a fair opportunity to be healthy. Without the practice of social emergency medicine, we run the risk of perpetuating health disparities. In order for ED providers to effectively practice social emergency medicine, hospital organizations must play an active supportive role. The ED is the front gate to the hospital. Hospitals should invest in EDs to implement interventions that incorporate social emergency medicine. Adopting a standardized tool for assessing patients' social needs and social risks facilitates clinical decision-making for ED providers. As ED providers we should be equipped to easily link patients to community resources upon discharge (Franks, Gipson, Kaltiso, Osborne, & Heron, 2021). Equipping EDs through use of technology with access to social workers, case managers, or community health workers supports the practice of social emergency medicine and achieving health equity.

Wyatt, Laderman, Botwinick, Mate, and Whittington (2016) outline a five-component framework that organizations should adopt to achieve health equity. These five components include: (1) make health equity a strategic priority, (2) develop structure and processes that support health equity, (3) deploy strategies that address SDOH, (4) develop partnerships with community organizations, and (5) decrease institutional racism within the organization. With this framework, social needs that are identified at the clinical microsystem level, such as the ED, can be addressed to meet the medical and social needs of vulnerable patients.

Hospital leadership must commit within all levels of the organization to implement supportive resources aimed at reducing health disparities. For example, allocating funds that are dedicated to equipping EDs with an appropriate infrastructure that will support and address SDOH is necessary. Deploying strategies that address SDOH includes developing ED workflows that incorporates an SDOH screening tool and community referrals will help establish support for health equity. There must be an established partnership with community organizations. For example, United Way offers 2-1-1 services across the United States. EDs should consider forming local partnership programs with community services such as this to help meet patients' needs. Opening the lines of communication between EDs and community organizations with the use of ED case managers and social workers facilitates the process of social emergency medicine. Hospitals must provide training for health care personnel on cultural and structural competence geared toward achieving health equity (Cooper, 2021). Strategies that focus on decreasing institutional racism require educating staff on implicit bias and eliminating the stereotyping of patients. Cultural competence is required for ED providers to initiate effective shared decision-making (Franks et al., 2021). The clinical decision-making process must also take into account SDOH. By doing so, we as providers optimize the best clinical outcomes for our patients.

CASE REVISITED

R.B. explains to the NP that she cannot afford Eliquis because she did not expect her co-pay to be so expensive. The NP at this point realizes that R.B. has an economic challenge that can prevent her from achieving the treatment she needs and risking a serious adverse health outcome. The NP understands the fundamental role SDOH plays in achieving quality heath and begins to ask further questions as she screens for other limitations or challenges that R.B. is currently experiencing that impacts the clinical decision-making process. At this point, the NP involves the ED social worker to assist R.B. with information for a prescription assistance program. With this assistance, R.B.'s co-pay is reduced to an amount she can afford. The social worker will follow up with R.B. to ensure she has all the resources she needs to continue with her Eliquis. Additionally, the pharmacist provides patient education for Eliquis while considering her level of health literacy.

Prior to discharge the NP orders a dose of Eliquis for R.B. to have in the ED. The NP also ensures that R.B. understands all discharge instructions and discusses with her how to arrange follow-up with a new primary care provider. The NP's knowledge of SDOH has facilitated the NP's clinical decision-making process and the coordination of appropriate resources for R.B. to overcome any access barriers to filling her Eliquis prescription. It is important to note that if R.B. had been screened at her first ED visit, a costly second and unnecessary visit would have been avoided. Additionally by screening R.B. early during her current visit, the NP better anticipated her social needs expediting her care and ensuring that she received the medication that was required at a cost she could afford.

CONCLUSION

As ED providers, we are at the frontline of social emergency medicine. Wallace et al.'s (2020) findings call for EDs to practice social emergency medicine by screening patients for SDOH to facilitate the coordination of resources required for quality treatment. To improve health equity and care, EDs should establish a model of care that incorporates screening tools for SDOH that can occur early during an ED visit or directly at the bedside. For this to occur, hospital leadership must engage in support and provide the appropriate infrastructure including use of technology and artificial intelligence for ED systems. Through new processes that easily incorporate assessment and implementation of services addressing SDOH, we can mitigate health disparities and move toward achieving health equity.

REFERENCES Anderson E. S., Lippert S., Newberry J., Bernstein E., Alter H. J., Wang N. E. (2016). Addressing Social determinants of health from the emergency department through social emergency medicine. Western Journal of Emergency Medicine, 17(4), 487–489. doi:10.5811/westjem.2016.5.30240 Cooper L. A. (2021). Why are health disparities everyone's problem? Baltimore, MD: Johns Hopkins University Press. Franks N. M., Gipson K., Kaltiso S. A., Osborne A., Heron S. L. (2021). The time is now: Racism and the responsibility of emergency medicine to be antiracist. Annals of Emergency Medicine, 78(5), 577–586. doi:10.1016/j.annemergmed.2021.05.003 Wallace A. S., Luther B., Guo J. W., Wang C. Y., Sisler S., Wong B. (2020). Implementing a social determinants screening and referral infrastructure during routine emergency department visits, Utah, 2017–2018. Preventing Chronic Disease, 17, E45. doi:10.5888/pcd17.190339 Wyatt R., Laderman M., Botwinick L., Mate K., Whittington J. (2016). Achieving health equity: A guide for health care organizations. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement.

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