Addressing The SDoH in The Emergency Department
By Tiffany Ferguson, LMSW, CMAC, ACM
A recent qualitative study published in the Journal of the American Medical Association (JAMA) explored the implementation of social determinants of health (SDoH) screening in U.S. emergency departments (EDs). The study aimed to identify the main themes that arose with the process of screening, documentation, and addressing SDoH concerns in this setting.
Researchers conducted in-depth interviews with leaders from 27 EDs across urban, rural, academic, and community settings who reported screening for SDoH. These participants, predominantly female (66.7 percent), held various leadership roles, including chairpersons and medical, nursing, or operation directors. The interviews, conducted between April and September 2023, were conducted with the goal of gathering insights into current practices and challenges related to adverse SDoH screening responses and subsequent referral processes.
Not surprisingly, the study found significant variability in how EDs screen for and document SDoH factors. This inconsistency reflects the absence of standardized protocols, leading to diverse approaches in identifying and recording patients’ social needs. The article noted that some ED leaders expressed doubts about the effectiveness of screening – and referring patients to services within the ED environment. The most significant concern was centered around the ED’s capacity to address these identified social needs effectively, given its primary focus on acute medical care. The findings go on to identify challenges related to lack of resources, staffing, and time to conduct screenings and facilitate appropriate referrals. These limitations hinder the ED’s ability to address patients’ social needs comprehensively. However, like a notion explored in the survey, the question remains: is the ED the best place to address these needs? Identifying issues and conducting follow-up do not have to happen at the same time if there is nothing urgent. Outside of personal safety, the questions surrounding the SDoH are not recent nuances to care; they are longstanding issues that patients have been facing.
The study did provide some recommendations:
They suggested revisiting the screening tools to align better with the fast-paced ED environment. They suggested involving ED personnel in the design and implementation process to ensure that the tools and workflows are practical and contextually appropriate. Finally, they requested employing additional staff, particularly social workers, to focus on the screening results to help alleviate the burden on medical staffs. Social workers are also skilled in identifying community resources and supporting patients and clinical staff with the moral distress that unmet SDoH needs create in a healthcare environment. Finally, they recommended aligning more with community resources and existing non-ED SDoH initiatives to facilitate effective referrals and patient support needs.
As we consider the continued requirements for SDoH screening in hospital outpatient departments, such as EDs, it is essential to consider key questions:
Does the patient want assistance with their unmet needs?
Is the patient already working with an agency or organization to address their unmet needs?
Given that these questions are being asked across nearly every healthcare setting, many patients may already be engaged with available services to address their SDoH concerns.
This study is commendable for emphasizing that resolving positive SDoH screenings does not necessarily need to occur in the ED, particularly if it does not impact the immediate medical care being provided. A potential approach could involve establishing post-ED outreach, where case managers and/or community health workers follow up with patients who screen positive, providing resources and referrals. If a patient’s needs are more complex, they could then be escalated to a social worker for further support.
Implementing SDoH screening in U.S. EDs presents both challenges and opportunities. While there is variability in current practices and skepticism about the utility of such screenings, targeted strategies such as improving screening tools, involving ED staff in process design, improving staffing models to address needs and requirements, and enhancing community collaborations can improve the effectiveness of these initiatives.