The emergency department (ED) has long been described as the, “safety net of the safety net,” providing care to anyone, for anything at any time, including the most vulnerable of populations. Emergency physicians have long seen the impact of social factors such as food scarcity, housing instability, and discrimination (including systemic racism) have on the health and well-being of our patients—issues that are pervasive regardless of one’s location or practice setting.
I disagree with those who assert that addressing social needs is outside the purview of the field of medicine. The COVID-19 pandemic is an extreme, but excellent, example of the interconnections between public policy and public health. As Dr. Rudolph Virchow famously stated, “medicine is a social science,” indicating that physicians cannot practice in a vacuum and ignore the social context of our patients’ (and our own) lives and experiences.
While the first step in creating change is to identify the problem, much more is needed to make a meaningful difference. Much scholarly work has been done identifying social needs among patients in the ED and elsewhere, and multiple pilot programs have been created to identify and address some of these needs in select populations. Be that as it may, numerous gaps remain, especially among ED populations, as described in the 2021 Society for Academic Medicine Consensus Conference which served to identify further research priorities within this arena.
Outside of the academic arena, changes can also be made to address these needs. The implementation of the Affordable Care Act in 2010, which incentivized many health care organizations to prioritize ‘value-based care’ and patient outcomes, may have provided some of the impetus for organizational changes. Currently, federal Medicaid rules do not allow for non-medical (i.e., social) expenditures, though this is not the case at the state level, and in January of 2021, the Center for Medicaid and Medicare Services (CMS) issued guidance educating states on how they may use allocations to “support states with designing programs, benefits, and services that can more effectively improve population health, reduce disability, and lower overall health care costs in the Medicaid and CHIP programs by addressing [social determinants of health].”
Of course, for a truly public-health centered approach, one must ensure solutions are evidence-based. The data from pilot studies to date are mixed, with some projects showing improvements in ED utilization and decreased inpatient hospitalizations, while others fail to show significant benefit. Indeed, the article reviewed in a recent Health Policy Journal Club column had similarly mixed results. Does this mean that efforts within health care to address social needs are untenable? I argue no. But rather, we must continue to study the problem and potential solutions (with an eye towards patient-centered outcomes) and encourage policy makers to ease the barriers to change. This will necessarily involve bringing our patients and our communities to the table, as the most important stakeholders in these efforts and as the reason we joined the profession in the first place. As Dr. Halloran mentions in her column, only five percent of health care dollars go towards population health improvement—an area ripe for growth if we are to improve the health and well-being of the patients we serve.
Care Coordination Decreased Inpatient Hospitalizations by 40% by Dr. diana halloran
The population of older adults is expected to double by 2050—and it is anticipated that emergency department visits and hospitalizations among this group will continue to rise. Given our already overburdened health care system, which has become even more strained with the COVID-19 pandemic, it will be pivotal to identify interventions that can reduce the strain on hospitals and health care workers.
A recent article did just that by assessing changes in health care utilization after enrolling older adults in a community care connection program.1 The program aimed to coordinate health care and social services for older adults to minimize hospitalizations and emergency department visits and to improve health outcomes. Interestingly, the program was associated with 40 percent fewer inpatient hospitalizations within the 90 days after program enrollment but was not associated with fewer ED visits. The authors suspect the absence of reduced ED visits could be due to errors in matching the enrollment group to the comparison adult group, underlying institutional or social factors, or the continued care-seeking behavior of the patients who desired to visit the ED.
Overall this paper is consistent with previous studies showing evidence of decreased hospitalizations upon the addition of social interventions. Managing patients’ medical issues without addressing their social needs ignores the effect of social determinants on health. The joining of health care and social programs, such as meal programs and care coordination, can be fundamental in improving health care systems and patient care overall. However, the data are not straightforward. A systematic review revealed the limited availability of research on emergency department visit reduction programs, and a recent randomized controlled trial regarding assigning health care super-utilizers to a care-transition program failed to reduce readmission rates. The union between health care and social programs remains a complex issue and the previously mentioned research demonstrates the need for additional studies and discussion in this area.
We as emergency physicians are aware of the importance that social needs have on health, yet the health care system itself lags behind. There remains a huge imbalance between national funding for health care and health improvement. Of the nearly four trillion dollars spent on health, 95 percent goes directly to medical care services, while just five percent is put aside for population health improvement. This represents a large area for opportunity to connect social services to health care, which could simultaneously improve patient health and reduce the burden on our health care system.
References
1 Fisher EM, Akiya K, Wells A, Li Y, Peck C, Pagán JA. Aligning social and health care services: The case of Community Care Connections. Prev Med. 2021 Feb;143:106350.
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