Prehospital Care Improving Continuity of Care through EMS Assessment of Social Determinants of Health

Improving Continuity of Care through EMS Assessment of Social Determinants of Health

By Mel Ebeling on behalf of the SAEM Global Emergency Medicine Academy

Seasoned with diesel fumes and CaviCide, my interviewing skills and ability to build quick rapport with my patients were two things I took great pride in when I started medical school. Yet, the transition from emergency medical technician (EMT) to medical student did not come without a great deal of turbulence and discomfort for me. In each of my interactions with standardized patients, something felt…off. I initially chalked this up to nerves, but after some introspection, I discovered that the fluidity and sense of ease of my interview characteristically began to drop off as I started taking the social history, when I became much more awkward. Despite knowing the significant impact of social determinants of health (SDOH) on health outcomes and the usefulness of that information in the development of a differential diagnosis, I still squirmed as I asked patients about their home life and education status. Why was this so? Why was there such a difference in how I felt interviewing patients now versus out in the field? In the field of emergency medical services (EMS), asking the patient about their SDOH is largely unnecessary, as we have the privilege of observing these factors at almost every call. We see people’s neighborhoods — those with a Trader Joe’s down the street and those with a Dollar General as the only grocery store nearby. We see the degrees on the walls and the hallways full of pictures of their support systems. We see the excess stairs leading up to the front entrance and the dusty car, indicating that this person may have trouble with mobility. We see the pile of bills on the kitchen table and cockroaches on the floor. We see, hear, and smell it all. To be invited into patients’ homes, in any state, is an honor, a window into their lives, and is a unique aspect of the profession. What if this could be harnessed to improve the health and lives of the people served by the emergency department (ED)?

Overutilization of EMS and EDs is an ongoing issue, and combined with an ever-increasing number of bureaucratic tasks, physicians must ultimately spend less time with each

“To be invited into patients’ homes, in any state, is an honor, a window into their lives, and is a unique aspect of the profession. What if this could be harnessed to improve the health and lives of the people served by the emergency department?”

patient to meet demands. Considering also that physicians do not work out in the field like EMS, the patient’s SDOH may never be adequately addressed in favor of mitigating the chief complaint in that limited window of time. Still, the ED is the prime link in the chain of health care services patients encounter for connecting them with the appropriate resources they need, whether that be housing, food, or some other social support. It would be beneficial, then, if EMS had the capability to objectively report observations from the scene regarding SDOH and share these observations via the electronic health record (EHR) to ED physicians and social workers.

Thus, a brief, standardized SDOH screener for transporting EMS agencies could provide invaluable information to the hospital staff responsible for identifying resources for patients. When SDOH are identified and confronted, ED utilization decreases and health outcomes are improved. While not all social determinants could be reasonably addressed, nor should it replace the communicating with the patient about their social history, this screener could allow EMS personnel the ability to note whether there were obvious health hazards (e.g., animal urine/feces everywhere inside), access to electricity, or environmental obstacles to mobility (e.g., hoarding conditions, staircases patients are unable to navigate, etc.), to name a few. First responders witness the spectrum of the human experience every day; utilizing their eyes and ears to improve health and wellness via a screener is a viable option. This is the basis of many community paramedicine programs; however, for jurisdictions without this resource, patients (especially those who utilize emergency services frequently) may never have their SDOH addressed.

The design and implementation of such a screener to improve continuity of care would require several things to be taken into consideration such as ensuring the interoperability between the EMS and hospital EHR systems; structuring items to ensure objectivity of responses, as to not promote prejudice or discrimination; and educating EMS and ED personnel on implicit bias and the impact of SDOH on health and wellbeing. Solutions for these considerations and specifics on screener design are outside the scope of the article, which is simply serving to propose a possible method by which continuity of care and health outcomes for emergency patients can be improved.

While we may not personally be involved in the creation of societal structures that affect the health of our patients, we still have a duty to address them. One of the ways we can accomplish that is to leverage EMS' ability to literally meet people where they are. If a description of vehicular damage in a trauma patient is important to the receiving ED, would it not also be important to know that the patient in diabetic ketoacidosis does not have the ability to refrigerate their insulin due to lack of electricity?

ABOUT THE AUTHOR

Mel Ebeling is a secondyear medical student at The University of Alabama at Birmingham Heersink School of Medicine and a practicing emergency medical technician (EMT) in the fire service. mebeling@uab.edu