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Admin & Clinical Operations Integrating Public Health with Emergency Department Care
By Tehreem Rehman, MD, MPH, on behalf of the SAEM ED Administration and Clinical Operations Committee
As emergency physicians, we see every patient that walks through the door no matter what language they speak, what their insurance status is, or whether they are a citizen of this country. The emergency department subsequently acts as a safety net setting for patients, especially those with complex social needs. Serving on the front lines of the community, emergency physicians are inevitably interacting with public health whether they realize it or not. I hope that at the end of this article, you will come away with a better understanding of how to leverage public health principles to your benefit to improve the experience and well-being of both patients and physicians in the emergency department. Similar to how a patient’s vital signs provide us with significant information about the patient’s physical status and risk for potential decompensation, “community vital signs” entail a more holistic inclusion of structural determinants of health to fully understand the factors driving a patient’s clinical presentation. These “community vital signs” include both individual-level structural determinants of health data and population-level data such as the Social Vulnerability Index derived from U.S. Census Bureau data. However, as we become more sophisticated with clinical informatics and information exchange systems, we will likely have the capacity to use more real-time data. One recent study found that data from 211 helpline calls may be more effective for risk stratification of patients with high emergency department (ED) utilization compared to more aggregate and less dynamic measures such as U.S. Census Bureau data. Incorporation of “community vital signs” into electronic health record data can help optimize understanding of all factors that inform the patient’s clinical presentation, treatment adherence, and ability to appropriately follow up. Thus, integrating public health with emergency department care allows physicians to successfully deliver “context-informed care,” ideally improving both health outcomes and patient satisfaction in the long term.
While integration of public health with clinical care in the ED is clearly important, we also need to be mindful of the time and other resource constraints that emergency physicians must navigate while also caring for critically ill patients. Subsequently, we cannot expect physicians to adequately address structural determinants of health among their patients without necessary organizational support. Department and hospital leaders must take the initiative in leveraging existing infrastructure and resources to spearhead change management and support physicians caring for patients with complex social needs on the frontlines.
One specific next step leaders can take is to push for the incorporation of “community vital signs” into clinical decision support and population management tools. This change management will likely require interdisciplinary stakeholder engagement and can produce deliverables such as dashboards and clinical workflows that yield actionable data.
As mentioned, efforts to integrate public health with emergency department care must be mindful about not increasing physician workload and, rather, be innovative about task-shifting with respect to screening and intervention delivery. That said, there is also mounting research demonstrating that physicians tend to experience disempowerment when it comes to addressing patients’ social needs, which in turn has been attributed to burnout. Ensuring that physicians are operating within a perceived organizational capacity to address structural determinants of health is pivotal to alleviating growing burnout. Additionally, as hospital capacity remains finite and ED overcrowding becomes an increasingly significant barrier to providing high quality care, physicians are incentivized to integrate public health frameworks with their care.
The benefit is twofold. On the one hand, patients who can obtain help with their complex social needs are less likely to clinically decompensate to the point of requiring an inpatient or ICU hospitalization. On the other hand, patients may be less likely to utilize the ED altogether with department resources now available for resuscitation and critical care efforts. In the long-run, emergency physicians can deliver high-quality care through minimized adverse effects of boarding in the ED while still feeling empowered to address underlying social factors contributing to a patient’s poor health.
Addressing structural determinants of health has been shown to improve the health and well-being of patients and entire communities; however, the need to demonstrate financial viability remains. Social need interventions typically take place outside of the walls of the hospitals and rely on cross-sector partnerships. As a result, it is not as simple to demonstrate a positive return on investment.
Hopefully, as we become more successful in integrating community vital signs into our electronic health record data, we will be able to better show the positive impact of social need interventions on both quality of care and cost reduction. For now, hospitals can take advantage of growing incentives for insurance companies to address structural determinants of health. For instance, North Carolina’s Medicaid system recently announced that it will start reimbursing social welfare agencies to provide services that address issues such as food insecurity, housing instability, and transportation barriers.
Emergency departments, at the nexus of interdisciplinary and front-line care, can facilitate such services as well. Ultimately, integrating public health with emergency department care can minimize costly care, such as of ambulatory care sensitive conditions, that yields increased ED utilization, inpatient hospitalizations, and more importantly, worse health outcomes.
ABOUT THE AUTHOR
Dr. Rehman is a physician and clinical instructor in the department of emergency medicine at the University of Colorado Anschutz Medical Campus. She is also an American College of Emergency Physicians Informatics and Quality Fellow and a section editor for the ED Administration, Quality and Safety section of the Western Journal of Emergency Medicine.
