Social Medicine in the Emergency Department: Not all conditions can be treated with medicines
On the day we met Jane, a woman in her 70’s with diabetes and mobility impairment, she was visiting an Emergency Department (ED) for the 50th time in the past year. Jane was experiencing homelessness and spent much of her day riding public transportation in her wheelchair. Bystanders, often concerned for her health after noticing she had an episode of incontinence, would call 911 after which Jane would be brought to the nearest ED.
On the day Jane came to our ED, our multidisciplinary ED-based Social Medicine team was asked to help in her care. She was very thin, her clothes were wet from rain, and her belongings were falling from the plastic bags draped on the back of her wheelchair. Our team sat with Jane to understand what type of help that she wanted — she was hungry, she hadn’t had stable access to food for months, and her bottom was painful as she had developed wounds from spending hours sitting in soiled clothes. That day, our team provided her with a sandwich and hot coffee, brought her a set of clean, dry clothes, and built enough rapport with her to interest her in moving indoors to a nearby respite center. Over the ensuing months, Jane gained back her strength, she established care with a primary care physician and improved her diabetes control, her wounds healed, and she built a relationship with a case manager who helped her to move into long-term housing. And, as a secondary outcome, her use of acute care services dropped substantially – she had less than 5 ED visits and no hospitalizations in the following year. Caring for Jane and watching what happened next was a lesson for all of us about the impact of addressing medical and social needs together.
What is an ED Social Medicine team?
We formed the ED Social Medicine team in 2017 to support ED clinicians and help better meet the complex medical, behavioral health, and social needs of ED patients. A brief description of our work was recently published in JAMA , which provides one potential roadmap to medical and social care integration in the ED. A few core components of this work include:
- Asking patients about their self-identified social needs – Meeting a patient’s psychosocial needs allows them to better engage with medical care.
- Supporting ED clinicians in the care of patients with complex behavioral health and social needs – The ED and acute care system cannot function optimally in a silo. The Social Medicine team is multi-disciplinary and includes hospital-based social workers, nurses, pharmacists, care coordinators, AND strong partnerships with ambulatory health care clinicians and community-based organizations essential to the safe discharge and successful care of ED patients with complex social needs.
- Considering how to best promote the individual patient’s health and independence while preserving access to acute care for all patients – Medical, social, and behavioral health resources in the community are often more robust than we might realize; clinicians and patients both win by better understanding the landscape of care and resources available in the community. Leveraging available community resources also allows the ED and inpatient hospital to be preserved for patients with the most emergent medical conditions.
Integrating the medical, behavioral, and social care for your patient
Treatment of medical conditions without consideration of underlying social needs will be less effective, more costly, and may lead to moral distress for both patients and providers. We all want to feel that we are treating the patient so that they will do as well as possible in their life outside the hospital — to address not just the immediate medical issue, but the things that are fundamental challenges in their lives.
For instance, when we are treating a patient in the ED with diabetes, homelessness, and social isolation, prescribing medication to treat hyperglycemia may be the most straightforward solution, but it is unlikely to be maximally effective without ensuring the patient can do the following:
- Afford the medication
- Get to the pharmacy
- Read the label and administer the medication
- Access affordable food
- Obtain transportation to follow up medical appointments
- Find a stable place to live
- Connect with social support in their community
These can seem daunting, and it may not be possible to improve all of these issues during the ED visit, but there are effective interventions to try to help patients experiencing complex social needs. As related to the example above:
- Arrange a conversation with a social worker to assess and address the patient’s social needs
- Dispense discharge medications directly from the ED
- Ask the pharmacist to consider how to make dosing easier such as a medi-set or special labeling for patients who speak a primary language other than English, or have visual impairment or low literacy
- Facilitate the next check up in primary care or other medical care by making an appointment or providing a warm handoff
- Provide printed information about social and community resources such as meal kitchens, food pantries, housing programs and community groups (such as support groups, faith communities and cultural organizations)
No matter what the problem, a first step is always to ask the patient what support they need in order to be successful.
Call to action for social medicine
- Partner up: We encourage you to understand the underlying social needs of your patients and work with partners, such as your ED social workers and community social services, to help meet those needs. The ED visit can be an opportunity to go beyond healthcare, and help our patients realize optimal health.
- Ask the patient: At the frontline, we recommend asking your patients about their primary concerns and social needs, and doing what you can to help.
- Form a team: If you want to go a step further, form a team and develop partnerships with staff in your ED (e.g., social workers) and outside your health setting (e.g., community based organizations) to understand a system problem (e.g., access to medications, food or emergency housing) more deeply. Talk to your patients to get their input and recommendations. Then, use quality improvement techniques to improve the care of that problem in service to your patients.
- Look upstream: If you want to work upstream of direct care, join or form a group to understand a problem at the community level and advocate for increased social services available to your organization and community.
If you want to learn more or get more involved in the Social Emergency Medicine space:
- Listen to our open-access interview on the JAMA podcast.
- Attend the upcoming 2021 SAEM Consensus Conference titled From Bedside to Policy: Advancing Social Emergency Medicine and Population Health Through Research, Collaboration, and Education
- Join the SAEM Social EM and Population Health Interest Group
- Join the ACEP Social Emergency Medicine Section
- Read this recent National Academies of Sciences, Engineering, and Medicine report on Social/Medical Care Integration, summarized in JAMA
- Read the 2019 Annals of Emergency Medicine Issue on Inventing Social Emergency Medicine
- Chase J, Bilinski J, Kanzaria HK. Caring for Emergency Department Patients With Complex Medical, Behavioral Health, and Social Needs. JAMA. 2020;324(24):2550-2551. doi:10.1001/jama.2020.17017
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