HOW CAN EMERGENCY DEPARTMENTS COLLABORATE WITH SOCIAL WELFARE INSTITUTIONS TO BETTER MEET OUR PATIENTS' HEALTH-RELATED SOCIAL NEEDS?

HEALTH ADVOCATES

Principal Investigator: Harrison Alter, M.D., M.S.

Project Directors: Dennis Hsieh, M.D., J.D., Resident, Department of Emergency Medicine; Lia Losonszy, M.D., M.P.H.,  Resident, Department of Emergency Medicine; Valerie Edwards, LCSW, Director, Department of Social Services; Rebecca Alvarado, MSW, Director, Health Advocates; Kimi Tahara, Coordinator, Health Advocates

Health Advocates is an innovative project, jointly developed by the Levitt Center and the Alameda Health System, that aims to enhance our capacity to meet the resource and legal needs of our patients from a perspective that recognizes the critical importance of social and economic determinants of health. We aim to improve the health of low-income patients, enhance the patient experience, increase access to primary care, and ultimately reduce emergency room utilization, inpatient hospitalization, and health care costs. The project brings together student volunteers, social workers, and lawyers to provide a continuum of care for our patients’ social, economic, and legal needs that allows each patient advocate to work at the top of his or her license.

The basic components during the initial phase of this project consist of the following:

  1. Conduct a needs-assessment of Emergency Services, Internal Medicine, and Social Services staff focused on understanding unmet patient social service and legal needs.
  2. Organize a resource database with the most commonly cited health, social service, and legal resources that patients need to access, such as emergency food, utility bill support, and substandard housing.
  3. Train Emergency Department and chronic care management clinic staff to refer appropriate patients to the Highland Health Advocates project.
  4. Recruit and train volunteer undergraduate, MSW, MPH, and law students passionate about community health to staff the Health Advocates project and work intensively with interested patients to meet their resource needs.
  5. Collaborate with the East Bay Community Law Center and other legal partners to provide free access to legal services through the project.

 This project has its roots in the creative resource desk model of Health Leads as well as the Medical-Legal Partnership (MLP) model. Health Leads is a non-profit organization that mobilizes the volunteer power of college students to connect patients with community services that are critical to health and well-being. Last year, Health Leads helped more than 9,000 patients across 21 sites to connect with a resource, and over 50% of these patients had one critical need solved within 90 days. The organization is in the process of conducting evaluations of their sites, and preliminary data suggests that the resource desks have decreased Emergency Department use in Washington, D.C., and lowered the percentage of low birth weight infants and increased patient and staff satisfaction in Chicago. In addition, these programs enable doctors, nurses, social workers, and other professionals to practice at the top of their skill set. This “task-shifting” is recognized by the WHO as a way to maximize the efficient use of health resources. We are also working collaboratively with a group of health professionals from other hospitals in the bay area interested in the Health Leads model, to share resource information and improve patient care and service coordination cross the regional health system.

 The other component of this project is the medical-legal partnership we have developed with the East Bay Community Law Center, with collaboration from Centro Legal and Bay Are Legal Aid. MLPs help to bridge the gap that often exists between a patient’s medical recovery in the hospital and barriers to health that exist in the home environment. Legal needs that directly impact health include access to public benefits, housing subsidies, sanitary housing conditions, discrimination in employment and education, legal asylum, and domestic violence. There is a growing body of evidence demonstrating the benefits of MLPs. One study focused on low-income and uninsured patients in Santa Clara county found that access to legal services resulted in significant increases in access to WIC (35.2% versus 50.0%), CalWorks (0.0% versus 9.3%), Food Stamps (13.0% versus 29.6%), Supplemental Security Income (5.6% versus 16.7%), and Child Support (7.4% versus 16.7%), as well as significant decrease in avoidance of health care due to concerns about cost (31.8% versus 13.6%). Another study that examined patients across ten MLP sites found that 70% of MLP patients felt empowered to access needed services versus 39% of non-participants, and 50% of those receiving legal services reported improvements in family well-being, including fewer hospitalizations, fewer asthma attacks, and decreased stress, anxiety, and depressive symptoms. Recent studies of three MLP sites have demonstrated that the cost-recovery from legal advocacy around issues such as disability and health insurance more than covers the cost of program implementation, even though cost-recovering cases are only a small proportion of cases handled.

The creation of Health Advocates incorporating both a Health Leads model and a medical-legal partnership with our existing social work staff at Highland has incredible potential to improve patient care, address social and economic determinants of health, and reduce overall healthcare costs.  The project opened in January 2013 with a focus on the Emergency Department and the HOPE clinic.  We quickly expanded to 7 desks throughout the Alameda Health System. 


STOP TRAFFICKING NOW: ENDING THE COMMERCIAL SEXUAL EXPLOITATION OF CHILDREN

Project Director: Hillary Larkin, PA-C

Principal Investigator: Harrison Alter, MS, MD 

The Levitt Center is actively engaged with other agencies in the Bay Area, particularly the HEAT (Human Exploitation And Trafficking) Watch initiative, to fashion a coordinated response by the medical community for trafficked children.  We are also working with researchers at UCSF, Stanford and UC Berkeley to understand better what are the needs of this most vulnerable group, and how the emergency care system might respond to these needs.

In addition, in 2015 Dr. Alter was named to the HEAT Institute, a statewide blue-ribbon commission exploring California's response to the scourge of modern slavery.  The commission completed hearings in mid-2016 and the Institute will complete its first report to the governor and the legislature with the year.


EVALUATION OF A TABLET-BASED DOMESTIC VIOLENCE REPORTING AND REFERRAL TOOL

Project Directors: Hilary Larkin, PA-C; Dana Kelly, PA-C, MPH

Funder: Alameda County Family Justice Center

The Levitt Center is spearheading a formative and summative evaluation of a novel tablet-based application, the Domestic Violence Reporting and Referral tool, in conjunction with the Alameda County Family Justice Center. The tool is designed to fulfill California providers' mandatory reporting duty while simultaneous uploading reports to officials in law enforcement, prosecutors and advocates. 


PRIOR PROJECTS:

EFFECTS OF RACIAL SEGREGATION ON NEIGHBORHOOD VIOLENT INJURY RATES

Project Director: Josh Berezin

Principal Investigator: Harrison Alter, MS, MD 

African Americans and Hispanics experience higher rates of violent injury and death than Whites. In 2004, homicide was the 21st leading cause of death for non-Hispanic Whites of all ages, but the 6th and 7th for African Americans and Hispanics respectively.  This disparity is particularly pronounced for young males. For example, among causes of death in males 20-24 years old, homicide accounted for 48.4% of deaths among African Americans, 25% of deaths among Hispanics, and 9.7% of deaths among Whites.

In attempting to explain these disparities, some scholars have examined the role of housing discrimination and its effect on communities. The United States has a long and ignominious history of racial residential segregation, which Douglas Massey defines as the “degree to which two or more groups live separately from one another, in different parts of the urban environment.”

A researcher associated with the Levitt Center, Josh Berezin, working with colleagues at UC Berkeley, performed a cross-sectional, ecological, neighborhood-level study of the relationship between diversity and violent injury in Oakland, California.  The methods involved determining the number of injuries in Oakland block groups, calculating a measure of diversity for those block groups, and analysis of the data.

Berezin and his co-investigators found that in block groups with at least one violent injury had a significant and inverse association between level of racial and ethnic diversity and rate of violent injury (IRR 0.22; 95% CI 0.10 – 0.48). They found a similar relationship for predominantly African American block groups (IRR 0.23; 95% CI 0.083 – 0.62) and predominantly Hispanic block groups (IRR 0.08; 95% CI 0.01 – 0.76).  Diversity was not significantly associated with violent injury in predominantly White or Asian block groups.