By Dorothy Brooks
Every day, frontline clinicians see patients presenting with medical problems exacerbated by unstable housing, lack of healthy food, substance use issues, or lack of money. Further, many such patients return repeatedly to the ED because these underlying social concerns continue to deleteriously affect their health.
This is a frustrating cycle for emergency providers who often lack the time and resources to delve into a patient’s complex needs. In fact, it is not uncommon for clinicians to suffer from moral distress over their inability to act on underlying social conditions that keep driving patients back to the ED.
What is the solution? A multidisciplinary group at Zuckerberg San Francisco General Hospital (SFGH) has created an ED Social Medicine (EDSM) team to deliver better outcomes for patients who present to the ED and to lift some burden off the shoulders of providers.
In operation since 2017, investigators are finding the EDSM team approach is delivering dividends on multiple fronts. They also believe they have created a roadmap to follow for other facilities struggling with similar concerns.
The creation of the EDSM team grew out of a push to address challenges related to patient flow across the organization, explains Hemal Kanzaria, MD, EDSM team co-developer and medical director of the department of care coordination at SFGH.
“We were actually encouraged by our executive team to think about and study how often patients are hospitalized for primarily complex social needs, and then to understand and develop some solutions around that [patient population],” he recalls.
Initial funding for this effort came from the San Francisco Health Plan, the main Medicaid managed care payor in the region. Developers studied how they could create better care capable of addressing medical and social needs. Concurrently, they wanted to provide an alternative to hospitalization for patients who present with lower medical acuity but higher social complexity. “You want to preserve those really precious hospital beds for patients who [require the kind of medical interventions] that can only be provided in the hospital,” Kanzaria says.
As a safety net hospital, SFGH sees many patients with medical and nonmedical needs, yet ED providers had been focused primarily on immediate medical concerns. However, Kanzaria says medical and nonmedical needs often are inextricably linked. “Those underlying social, environmental, and economic needs are really foundational to a person’s health. If my job is to improve [a patient’s] health overall, I need to be skilled at meeting both their medical and social needs,” he says. “This program allows us to get closer to ... the foundational needs of those patients who are presenting here.”
There were times when Kanzaria believed he should admit a patient and hope that sometime during the stay a solution would emerge to address the lack of housing, food insecurity, or financial distress. Alternatively, clinicians would just discharge the patient to an unsupported environment.
The EDSM team is designed to offer emergency providers a third alternative: Do right by the patient — and with tools at their disposal to achieve that goal.
Jenna Bilinski, RN, MBA, director of health operations, social medicine, and the Kaizen promotion office at SFGH, says the EDSM team is fortunate to work in an organization that is mission-driven and supports doing what is right for patients. “When you work in a safety net organization and your point of entry for folks is the ED, then you should be putting the services they need the most at the point of entry,” she says. “That is really what our focus has been ... and it has turned out to be beneficial for both the organization and for the people we are serving.”
The EDSM has grown to include a patient navigator, multiple physicians, a pharmacist, social workers, care coordination nurses, and transitional care staff. The team also has nurtured multiple links with community resources such as substance use treatment providers, housing assistance groups, behavioral health providers, and organizations that can assist people dealing with food insecurity or domestic violence.
Jack Chase, MD, FAAFP, FHIM, co-developer of the EDSM team, recalls the recent case of a woman in her 70s who struggled to walk, lived with chronic hearing loss, and had fallen in her home where she lives alone. “She called 911 and was brought to the ED for evaluation and had a laceration on her forehead,” says Chase, associate professor of family community medicine at the University of California, San Francisco. “The ED team that received her overnight [told] the day team that they felt very concerned about the patient’s safety.”
Chase, who was the consulting physician on the EDSM team that morning, learned about the case as he and other team members were rounding with the day shift clinicians in the ED. The attending physician was worried about the prospect of sending the patient home.
“[The attending] was seeing this person in front of her who she felt was very unsupported in the community, high risk, had just fallen, and had a significant head injury that required stitches,” Chase recalls. “How were we going to make sure that it was safe for her to go home?”
After reviewing the case with the attending physician, Chase and other EDSM members visited the patient to hear her concerns and what she wanted from the ED encounter. “The patient was very clear. She was desperate to go home. She really did not want to be hospitalized and she did not want to go into long-term care. She was actually very satisfied with her home environment,” Chase explains.
However, considering the patient’s wishes did not alleviate the attending’s concerns, there was a conversation among the attending, the patient’s primary care provider (PCP), and the EDSM team. “We understood a little bit more about her longstanding values and healthcare-related needs,” Chase observes. “She didn’t have a hearing aid, and she had no help at home. We facilitated a referral for a home health team to go and visit her. We actually purchased — with dedicated funding — a hearing aid for the patient so she could ... better communicate with the PCP and her new home nurse.”
In addition, the EDSM team ensured the patient received food delivery, and coordinated with the PCP to follow up after discharge. All these steps reassured the attending the patient would receive appropriate care. “It’s a nice example of coordination of care throughout the system involving multiple disciplines,” Chase shares. “We were meeting different kinds of needs, and [our efforts] also aligned with what the patient’s values were.”
Besides regular rounding, there are multiple other ways the team can be brought into a case. For instance, an emergency provider can call the patient care coordinator or the consulting physician who is on service with the EDSM team that day. Nurse managers in the ED also will email the EDSM team about a patient.
“Increasingly, over the course of our team’s existence, as word has gotten out about our team, people actually reach out to us about clients who are not even in the ED at the current time,” Kanzaria observes. “We get referrals from protective service social workers who are caring for clients they are worried about. In a previous iteration, they would have just brought the patient to the ED and said they were concerned about the patient’s safety, [indicating he or she] just needs to be hospitalized.”
Now, there often is some prework whereby the social workers contact the EDSM team. They work together while the patient is in the community to either beef up services there or try some other alternatives before the patient comes to the ED.
Such steps are the result of increasingly robust relationships the EDSM team has formed with community organizations. “Adult protective services has started reaching out to us about clients who they are worried about,” Chase reports. “We have had some really moving examples of people who were being abused or physically threatened in their home environment.”
In such cases, the EDSM team often will partner with a community-based social services organization to create a plan that provides for needed services and a safe environment. “We know that we always have a backup safety net in that the patient can always be transported to the ED at any point, and we will help to facilitate their care within the building if need be,” Chase says.
However, in many instances, such collaborative planning can put these individuals in a safe environment and ensure their medical needs are met without an ED trip.
Prioritize Mental Health
Patients who present to the ED with significant social needs often live with behavioral health issues, too. Kanzaria notes most patients the EDSM team works with present with some combination of substance use disorder, mental illness, homelessness, and low-level medical acuity.
While addressing such needs in an expeditious manner can be difficult, SFGH offers a psychiatric emergency service that operates next to the medical ED 24/7. “We work closely with [the staff there], and we collaborate on a number of patients because people will present to both places,” Kanzaria explains.
For example, there was a young woman with a history of severe trauma involving both physical and sexual abuse. She suffered from symptoms of PTSD, experienced instances of panic and severe agitation, and also was battling a comorbid substance use disorder. “All of those symptoms and behaviors had resulted in her being denied service at various community-based settings,” Chase explains. “This rendered her with basically not a lot of options. She would just end up coming to the ED or psychological emergency services over and over again in really severe crisis.”
The EDSM team decided to convene a meeting with representatives from various community organizations, the inpatient psychiatry consult team, psychiatric emergency physicians, and representatives from some residential treatment centers. Meeting participants agreed the next time the patient presented to the ED, clinicians would try to provide her with medications to reduce her psychosis while also presenting options for further treatment.
They understood the patient might be so ill she would have to be involuntarily observed for psychiatric treatment for a period until she was stabilized enough to voluntarily engage in treatment. Ultimately, the plan proved successful.
“The next time this patient showed up, she was hospitalized and provided with acute mental health treatment for crisis. She started on medication, and she started on groups,” Chase notes. “There were some ups and downs ... and there were some episodes of agitation that she had, but they were manageable.”
At the end of acute treatment, the patient transitioned to a treatment program where she stabilized. “Our role there was to try to bring people together, and to lower the barriers to doing the right thing for the patient,” Chase adds.
Test Ideas, Interventions
On a typical day, the EDSM team will work with three or four patients who present to the ED. While the number of patients who could benefit from engaging with the EDSM team far exceeds the group’s current capacity, data show the multidisciplinary approach to addressing patient needs is making a difference.
“We have served well over 4,500 patients, and we have multiple different initiatives,” Kanzaria explains.
For instance, one initiative that provides medications free to patients who cannot access them has helped more than 2,000 people. Another initiative has helped more than 230 vulnerable clients obtain stable housing. “We have helped to avert 600 to 700 admissions or readmissions ... mostly by offering support and providing a safe alternative to hospital care,” Kanzaria adds.
Further, in a study Chase, Kanzaria, and Bilinski published about the EDSM team, they reported 60-day ED use following an EDSM consultation decreased by 5.8% from October 2017 to March 2020.1
While the EDSM team continues to expand, Kanzaria’s advice to leaders thinking about following a similar path is to understand the local landscape.
“Look at what your patient and community needs are, and use data to make transparent what these needs are — whether [they include] financial insecurity, food insecurity, access to affordable housing, or healthy food,” he offers.
Then, it is a matter of devising potential solutions to apply to the identified needs, and testing to see if they are effective. When successful, use the results to obtain support. “We were able to garner interest from our hospital leadership and our city leadership to expand on our initial ideas. We have been fortunate to have some success,” Kanzaria explains.
With any investment of resources, there will be concerns. At SFGH, ED leaders wanted to know how EDSM team consultations would affect operational metrics such as length of stay.
“We were able to understand those concerns, and then overcome them with data,” Kanzaria says. “We were also able to engage with [the hospital’s] executive team and align what we were trying to do with what their needs were.”
Kanzaria urges clinicians to advance their understanding of the underlying social, environmental, and economic factors that drive health.
“If you are taking care of a patient with an infection, cancer, or congestive heart failure who also is experiencing homelessness, unless you are someone who recognizes the impact of homelessness on that person’s health, there is a missed opportunity to advocate and to help your patient to improve their health,” he observes.
Even in hospitals without the kind of resources available to SFGH, an emergency clinician might partner with a social worker or pharmacist to address an identified social need in a patient or the community. The idea is to make the effort multidisciplinary.
“You also want to look beyond your hospital. You can’t do this in a silo,” Kanzaria says. “Healthcare systems have to partner with ... community organizations and community members outside of the medical care system to advance the community’s health.”
- Chase J, Bilinski J, Kanzaria H. Caring for emergency department patients with complex medical, behavioral health and social needs. JAMA 2020;324:2550-2551.