Emergency Department

Lynton Scholar Austin Kilaru, MD, Reflects on the SEM Consensus Conference, September 2017

A week after returning from Dallas, I had lunch with my fellow fourth year residents. They are all compassionate, fierce advocates for patients, and without hesitation they support the principles of social emergency medicine. It would be difficult to not do so after training at our under-resourced county hospital. Yet they expressed valid skepticism for the implications of social EM in their practice. As grizzled senior residents, they have met frustration in trying to help patients with bleak housing situations or severe substance abuse disorder. They also have seen how fast and loose the practice of emergency medicine can be in the community. They did not doubt that social determinants of health were the key driver of patient outcomes, but they felt a lack of empowerment to recognize and intervene on those social determinants during a Tuesday night shift.

Empowerment is the key word that I reflect on even months after the Inventing Social Emergency Medicine conference. I believe that all emergency physicians want to practice social emergency medicine. But they need the tools to do so. And the tools have to meet the demands of our daily practice.

I was surprised with the outward-facing nature of the discussion in Dallas. The participants were a select group of researchers and community leaders with whom I was honored to even share the same room. Yet they recognized the need to make social EM relevant and vital to all emergency departments and providers.

How can we empower physicians and nurses to screen for social determinants of health? How can we help them help patients? I now believe this to be the central research and policy question in social EM, for whatever domain you might consider: housing, substance abuse, intimate partner violence, healthcare access.

Part of the conference discussion centered on the idea that to practice good emergency medicine was to practice social emergency medicine. None of us can adequately treat back pain if we do not ask whether patients use injection drugs. None of us can discharge a patient with pneumonia if there is no way for them to fill a prescription for antibiotics. These are the questions that we should be asking, and for the most part, many of us are.

Yet we can and should extend our work beyond screening and addressing acute illness. We should be able to initiate substance abuse treatment for the patient with back pain when their MRI is negative. We should be ale to find a medical respite or medication assistance to the patient with pneumonia and avoid a costly and preventable hospital admission. For this next level, we cannot expect emergency physicians to invent these solutions on the fly – there are twenty patients in the waiting room and a line of ambulances waiting for triage. These solutions must be developed outside of the shift. We should empower champions to engage in this work, making this part of the central administrative and quality efforts of every emergency department.

Another thread of the conference discussion focused on the need for both local and structural responses for social EM. Local solutions are needed for local problems, finding housing options, obtaining access to mental health resources, or developing programs for complex care management. One of the key strategies should be to find community partners and resources that already exist, and to integrate the work of the ED more fully into the community.

At the same time, there are larger policy and regulatory interventions that can drive and sustain these efforts. Policymakers, regulators, insurers, public health advocates – they can set expectations for every emergency department, whether urban, rural, county, private, or academic. We can enlist JCAHO and CMS to make sure every ED provides social work and case management, makes policies to screen for social determinants of health, and provides solutions to common patient problems. EMTALA, in some ways, was the first and most consequential policy to address social emergency medicine – we now have to deliver on its initial promise and truly provide people with the stabilizing care that they need. The role of research should be to find evidence-based, effective interventions that allow the development of policies and system changes.

My fellow fourth year residents are ready to embark on careers in emergency medicine, and we are all headed in different directions. One thing that unites us is the motivation to do our best for our patients. The promise of social emergency medicine is to make our best even better. Ultimately, empowerment does not just benefit our patients – we will have more rewarding careers, face less frustration and burn-out, and stay true to our original vision for becoming physicians.

Lynton Scholar Theresa Cheng, MD, Reflects on the SEM Consensus Conference, September 2017

The local Emergency Department (ED) is a microcosm of its surrounding communities and the social determinants of health impacting residents’ abilities to pursue individual wellbeing. As our societal safety net, EDs – and the providers within – are in a unique position to address medical and social emergencies. Emergency physicians are given the opportunity to intervene on behalf of patients as advocates of essential medical and social needs. Social Emergency Medicine (SEM) is a timely and increasingly necessary field as the future of our healthcare system is becoming more uncertain and more patients find themselves seeking the ED as a last resort. Institutionalizing SEM through the consensus conference “Inventing Social Emergency Medicine” formally establishes the field, providing context and space from which EM providers may work. As a Lynton Scholar, I was privy to this roundtable discussion that assembled leaders of the field, from experienced forebears of Emergency Medicine to current trailblazers in SEM research. While participants presented distinct research on topics such as homelessness and community violence, the common goal of health equity was palpable throughout – the conference was a chance to define, mediate, and enhance the interplay between medicine and social justice that naturally exists in the ED. Central to our discussions was the recognition of the need to expand the ED’s role in incorporating population-based health research and interventions while leveraging already-established resources in local communities. Stronger ties with fellow providers, such as social workers and nurse practitioners, would bolster our abilities to address social needs in the ED; meanwhile, connecting with unexpected allies, such as lawyers and anthropologists, would innovate the way we deliver this care. By integrating social structural analyses to medical and public health curricula, we would be providing future generations of health professionals with the lenses to identify, treat, and ultimately prevent social determinants leading to disease. The need for SEM, as reflected in the realities of many of the patients we encounter in the ED, extends beyond the moral imperative as this pragmatic approach can help to reduce ED recidivism and overall healthcare costs. By identifying and addressing our patients’ unmet social needs, we seek to disrupt the multi-faceted causes of their illness and improve the overall health trajectory. Through “Inventing Social Emergency Medicine” and future such collaborations and conferences, SEM has become not just a doctrine within medicine, but a way of practice and a way forward in advancing health justice.

Post Script: I am extremely grateful for the Lynton Scholarship that allowed me to take part in the inaugural conference of social emergency medicine. Many thanks to the family of Jamie and Michael Lynton as well as the Andrew Levitt Center for Social Emergency Medicine for this momentous opportunity.

A Skeptic’s Guide to Social Emergency Medicine

Most of us of a certain age have our favorite Sesame Street character. Mine? Oscar. That grumpy old green guy. Oscar sticks his head up out of his trashcan whenever something new is happening on the block and renders his assessment which is generally something fairly snarky. I identify with the green fella. (This will come as no surprise to the EM residents in our ED.) I prefer to think that beneath that mussed up hair and those big brown eyebrows lives a gimlet-eyed observer, one who generally ignores Big Bird’s cheerleading and prefers to make his own assessment of the Cookie Monster’s latest antics. Maybe the reason I’ve always liked Oscar best – I’ll admit it – is because he continually invokes that most critical yardstick, “What’s in it for me?”

If I’m Oscar, and the Emergency Department is my street, then any dreaded “new ED initiative” is what gets me to stick my grumpy head up out of the trashcan. And “What’s in it for me?” can be restated as “How much are my patients really going to benefit from this?” and “At what cost, in terms of additional work, for yours truly?” How many more forms and phone calls are required? We old timers find ourselves overwhelmed most of the time as it is. Just figuring out what’s wrong with our patients, and managing them correctly, is challenging enough. It’s a zero sum game here. Either I attend to this new initiative, or that one, or I spend a few extra minutes with my patient, but I can only do one of those things.

Now comes Social Emergency Medicine, and up pops my trash can lid. What are the do-gooders going to ask me to do now? Public health screening? Help desks? So nebulous. What does it all mean? It sounds like more work for me. How will this benefit my patients today? Am I right? People, am I right?!

Well, guess what? This old Oscar is now a believer, and I’m here to help all you other Oscars out there understand why. The concept of Social Emergency Medicine encompasses an almost infinite number of potential initiatives. But I can say first-hand, based on what’s been done in our ED, that several of them are actually pretty easy to get one’s head around. And, when executed well, they can provide rapid, concrete, clinical benefits for patients with minimal extra work for busy emergency physicians. Here’s my top four list:

  1. ED help desks
  2. Buprenorphine for opioid misuse
  3. HIV and hepatitis C screening
  4. Health coaches in the ED

Let’s start at the top. Here is the skeptic’s guide to what are known as “ED Help Desks.”

At the heart of Social Emergency Medicine is the notion that there is a set of all-important, yet often under-recognized, “social determinants of health” – things such as housing, food and financial insecurity, legal entanglements – which all too frequently are the real reason patients come to the ED. At a safety net hospital such as mine, the expectation that our heroic but harried ED social workers will be able to tackle most of these problems is not realistic.

Enter the ED help desk. In its classic form, a help desk is just that, a desk, located just outside the ED or clinic, staffed by volunteers, often undergraduates, overseen by social workers and lawyers, who sit ready to assist patients in addressing these social determinants of health. Volunteers provide a variety of services including helping patients apply for food stamps and paratransit, finding affordable childcare or legal services to prevent an eviction, and paying utility bills. The help desk is perhaps the purest expression of what social emergency medicine is all about.

The idea of the help desk, and using college student volunteers, originated in Boston in the late 1990’s, with Rebecca Onie and Health Leads. The aim of Health Leads, which now offers proprietary consulting services (in essence, ready-made help desk solutions), is to “operationalize equity” and “create sustainable, high-impact and cost-effective social needs interventions that connect patients to the community-based resources they need to be healthy.”

The help desk origin story at our ED goes like this. One day in 2012, a patient arrived on a psychiatric hold, restrained and hysterical, after melting down in the housing authority lobby and threatening to kill herself if her Section 8 housing voucher was taken away. As luck would have it, her ED provider that day was second year resident, Dennis Hsieh. Dennis happened to be a law school graduate and already an expert on medical-legal partnerships to assist the underserved. As the story goes, Dr. Hsieh walked back out of the patient’s room after a few minutes. “That woman doesn’t need a psychiatrist,” he fumed, “She needs a lawyer!” Dr. Hsieh and Dr. Harrison Alter went on to start the ED help desk, called Highland Health Advocates, at our hospital.

Like the other Social Emergency Medicine initiatives on my list, a help desk needs champions, and an investment of resources. Fortunately, the challenge of addressing social determinants of health is not unique to emergency medicine. It is a challenge, and frustration, shared by physicians in many specialties, and their social work colleagues, in every medical center that works primarily with underserved patient populations. These medical centers, through their departments of family practice, pediatrics, geriatrics, etc, can marshal and share resources to create help desks at their individual sites. There are now help desks located at Stanford Medical Center, San Francisco General Hospital and the UCSF Benioff Children’s Hospital pediatric ED. There is even a Bay Area Regional Help Desk Consortium to foster a regional approach, help with implementation, and share lessons learned.

To ED doctors, the idea of a help desk may seem like something more suited to a primary care clinic, the patient’s medical home. Yet we all know that, for many of our patients, the ED is the only point of contact with the healthcare system. If we don’t link them with the services provided by a help desk, it will never happen. And, when the help desk succeeds, say by obtaining a paratransit pass for your disabled patient, it increases the chances that that patient can, and actually will, make it to their primary care appointment. This could mean one less frequent flier for you. Oscar would immediately recognize it as a classic example of helping oneself by helping one’s patients.

Likewise, ED social workers – who are forced to triage their own time and often can only attend to the most immediate crises – recognize that help desks offer a more proactive approach and can focus on patients’ long-term social problems. Ezra, one of our ED social workers, tells the story of a woman whose already sketchy living situation was lost to fire. Living among drug users, and with mental health issues of her own, she had previously come to our ED many times. Ezra was able to find a short-term placement for her, but he then referred her to Highland Health Advocates. There a volunteer spent 3 hours helping her sign up for food stamps, Salvation Army Fire Relief and a Section 8 housing wait list. When Ezra checked on her progress, the patient hugged him and the volunteer and, in tears, said she felt optimistic about her future for the first time in years.

OK, so let’s say you buy this notion that social determinants of health directly underlie many ED visits. And, yeah, you are always willing to try and address your patient’s real problem, even if it’s not life-threatening. Further, let’s suppose some other far more big-hearted and ambitious colleague has actually established a help desk outside your ED. How do you know which patients to refer? Dennis Hseih gives these pointers. The first clue, often, is you find yourself wondering, “WTF? Why is this patient here?” Those are the patients whom you should then ask, “Do you have somewhere safe to stay?” and “Do you have enough money for food and for your medications?”

By making that well-targeted help desk referral, you stand to turn a “waste of your time” into a positive encounter – one that could have a lasting, beneficial effect for your patient.

In my next blog post, I’ll show you how another Social Emergency Medicine initiative, identifying opioid misuse and prescribing buprenorphine from the ED, stands to similarly transform the dreaded “drug seeker” encounter.


Interested in learning more about Social Emergency Medicine, social determinants of health and help desks? Check out these resources:

Bay Area Help Desks

https://www.calhospital.org/general-information/web-forum-registration-bay-area-regional-help-desk

Stanford Health Advocacy and Research in the Emergency Department SHAR(ED)

http://emed.stanford.edu/specialized-programs/sem/shared/help-desk.html

Social Interventions Research and Evaluation Network (SIREN)

https://sirenetwork.ucsf.edu/

Health Leads

https://www.ted.com/talks/rebecca_onie_what_if_our_healthcare_system_kept_us_healthy/transcript#t-259680https://healthleadsusa.org/about-us/vision/