By Christopher Cheney
An emergency department social medicine (EDSM) team at a San Francisco-based hospital has improved the care of patients with psychosocial needs.
Treating patients with behavioral health issues such as substance abuse and social challenges such as homelessness pose several difficulties in emergency departments. For example, ED clinicians are under time pressure to treat patients with acute medical conditions and ED staff typically have limited links to community-based organizations.
The EDSM team at Zuckerberg San Francisco General Hospital and Trauma Center was detailed recently in an article published by the Journal of the American Medical Association. The EDSM team at the hospital includes a patient navigator, social workers, care coordination nurses, a pharmacist, physician consultants, and specialists in transitional care, substance use, and quality improvement.
The journal article features four key data points:
- From October 2017 to March 2020, the EDSM team conducted nearly 4,000 consultations to assess and coordinate care for patients, which prevented 567 admissions and 127 readmissions
- More than 1,100 patients were given discharge medications at no charge and received pharmacist education about their medications before discharge
- For patients treated by the EDSM team, mean ED length of stay was 345.8 minutes, which was just slightly higher than the 344-minute length of stay of all other ED patients
- 60-day ED utilization decreased 5.8% for patients treated by the EDSM team
Medications were provided free of charge to ED patients with barriers to medication access to promote safer discharge to the community.
The EDSM team worked closely with the ED staff, the journal article’s co-authors wrote.
“At a standard time daily, the EDSM team rounded in the ED to elicit referrals from clinicians for patients experiencing homelessness, substance use, mental illness, food insecurity, intimate partner violence, and gaps in medication access, health insurance coverage, ambulatory care, and home-based services. Throughout the day, the EDSM team reviewed the electronic health records for ED patients with psychosocial needs. Additionally, ED clinicians and nurses proactively discussed psychosocially complex patients with the EDSM patient navigator by phone or in person. Once a patient referral was identified, the EDSM team integrated the psychosocial and medical aspects of care in consultation with the ED clinical team prior to patient ED discharge or admission.”
Connecting patients with services
The EDSM team works with patients and ED clinicians to connect patients with services after discharge, the lead author of the journal article told HealthLeaders.
“The EDSM multidisciplinary team starts by meeting with the patient to understand his or her self-identified needs. In parallel, the team solicits input from the ED clinician on the medical issues and clinician concerns. Once a plan is created in partnership with the patient and ED clinician, EDSM team members call community-based partners including substance use treatment programs, social workers, case managers, food programs, emergency housing programs, and other community-based social services to facilitate enrollment and service delivery after discharge from the ED,” said Jack Chase, MD, co-director of social medicine at Zuckerberg San Francisco General Hospital and Trauma Center.
The EDSM team works closely with staff in the San Francisco Department of Public Health and other city agencies to make community social service connections, he said.
EDSM team members also connect patients with ambulatory care providers, Chase said. These providers include primary and specialty medical care, mental health care, and substance-abuse treatment providers. These connections are made through the electronic medical record and by email to provide ongoing support, to arrange case conferences to discuss complicated patient care situations, and to facilitate referrals after discharge, he said.
Role of social medicine consultants
The EDSM teams social medicine consultants play a crucial role for patients and ED clinical staff, Chase said.
“Our social medicine consultants, soon to include a nurse practitioner in addition to physicians, employ a service-based mindset to meet the patient’s self-identified needs while also providing clinical guidance, reassurance, and extra work capacity to our ED clinical colleagues. We recognize that our ED clinical colleagues are managing acute medical emergencies such as stroke, respiratory failure, cardiac arrest, and trauma while simultaneously managing behavioral health and social emergencies, including substance use relapse, psychosis, homelessness, starvation, extreme poverty, and social isolation,” he said.
The EDSM team focuses on the care of patients with less acute medical issues and more prominent behavioral and social needs, Chase said.
“Our goal is to meet the patient’s self-identified needs in the most efficient and successful way possible while also providing our ED clinical colleagues with a preferable alternative to admission for social needs or discharge without adequate support. To integrate a bio-psycho-social plan, key elements of this work include direct EDSM clinician to ED clinician communication and consultation, augmenting community-based services to meet a patient’s needs, and care coordination with community-based clinicians to support comprehensive outpatient care.”
Creating and sustaining EDSM teams
The EDSM team initiative at Zuckerberg San Francisco General Hospital and Trauma Center targeted a specific goal when the program was created, Chase said.
“Our initial vision of using a multidisciplinary team to provide more comprehensive care in the ED came from using a quality improvement mindset to understand a central problem affecting our patients and our hospital: How to meet the complex medical, social, and behavioral health needs for patients in the ED while preserving acute care services and bed space within the hospital for patients with the highest level of medical acuity.”
He offered advice for how other hospitals can start an EDSM team program.
“We would recommend that hospitals start by reviewing their own patient and community data and identifying what challenges they see in relation to caring for patients with complex needs. Once data on patients’ health-related social needs are defined and the reasons for unmet needs are understood, we recommend using performance improvement methodology to identify initial small tests of change to make progressive enhancements. Additionally, we recommend stakeholder engagement and team-building with community partners and existing community social services.”
There are crucial elements to sustain an EDSM team program, Chase said.
“One key to success in securing support and acquiring funding has been our use of data to demonstrate effectiveness of each intervention coupled with patient stories to demonstrate the human impact of this model of care. Additional elements of our model include empowering frontline staff to drive improvement based on their own daily experiences in clinical care and creating space within the program for professional development. The latter effort supports increased training and certification to allow team members to fulfill the highest level of their licensure and credentials while building new, more sophisticated skills in the process.”
Christopher Cheney is the senior clinical care editor at HealthLeaders.