Most of us of a certain age have our favorite Sesame Street character. Mine? Oscar. That grumpy old green guy. Oscar sticks his head up out of his trashcan whenever something new is happening on the block and renders his assessment which is generally something fairly snarky. I identify with the green fella. (This will come as no surprise to the EM residents in our ED.) I prefer to think that beneath that mussed up hair and those big brown eyebrows lives a gimlet-eyed observer, one who generally ignores Big Bird’s cheerleading and prefers to make his own assessment of the Cookie Monster’s latest antics. Maybe the reason I’ve always liked Oscar best – I’ll admit it – is because he continually invokes that most critical yardstick, “What’s in it for me?”
If I’m Oscar, and the Emergency Department is my street, then any dreaded “new ED initiative” is what gets me to stick my grumpy head up out of the trashcan. And “What’s in it for me?” can be restated as “How much are my patients really going to benefit from this?” and “At what cost, in terms of additional work, for yours truly?” How many more forms and phone calls are required? We old timers find ourselves overwhelmed most of the time as it is. Just figuring out what’s wrong with our patients, and managing them correctly, is challenging enough. It’s a zero sum game here. Either I attend to this new initiative, or that one, or I spend a few extra minutes with my patient, but I can only do one of those things.
Now comes Social Emergency Medicine, and up pops my trash can lid. What are the do-gooders going to ask me to do now? Public health screening? Help desks? So nebulous. What does it all mean? It sounds like more work for me. How will this benefit my patients today? Am I right? People, am I right?!
Well, guess what? This old Oscar is now a believer, and I’m here to help all you other Oscars out there understand why. The concept of Social Emergency Medicine encompasses an almost infinite number of potential initiatives. But I can say first-hand, based on what’s been done in our ED, that several of them are actually pretty easy to get one’s head around. And, when executed well, they can provide rapid, concrete, clinical benefits for patients with minimal extra work for busy emergency physicians. Here’s my top four list:
- ED help desks
- Buprenorphine for opioid misuse
- HIV and hepatitis C screening
- Health coaches in the ED
Let’s start at the top. Here is the skeptic’s guide to what are known as “ED Help Desks.”
At the heart of Social Emergency Medicine is the notion that there is a set of all-important, yet often under-recognized, “social determinants of health” – things such as housing, food and financial insecurity, legal entanglements – which all too frequently are the real reason patients come to the ED. At a safety net hospital such as mine, the expectation that our heroic but harried ED social workers will be able to tackle most of these problems is not realistic.
Enter the ED help desk. In its classic form, a help desk is just that, a desk, located just outside the ED or clinic, staffed by volunteers, often undergraduates, overseen by social workers and lawyers, who sit ready to assist patients in addressing these social determinants of health. Volunteers provide a variety of services including helping patients apply for food stamps and paratransit, finding affordable childcare or legal services to prevent an eviction, and paying utility bills. The help desk is perhaps the purest expression of what social emergency medicine is all about.
The idea of the help desk, and using college student volunteers, originated in Boston in the late 1990’s, with Rebecca Onie and Health Leads. The aim of Health Leads, which now offers proprietary consulting services (in essence, ready-made help desk solutions), is to “operationalize equity” and “create sustainable, high-impact and cost-effective social needs interventions that connect patients to the community-based resources they need to be healthy.”
The help desk origin story at our ED goes like this. One day in 2012, a patient arrived on a psychiatric hold, restrained and hysterical, after melting down in the housing authority lobby and threatening to kill herself if her Section 8 housing voucher was taken away. As luck would have it, her ED provider that day was second year resident, Dennis Hsieh. Dennis happened to be a law school graduate and already an expert on medical-legal partnerships to assist the underserved. As the story goes, Dr. Hsieh walked back out of the patient’s room after a few minutes. “That woman doesn’t need a psychiatrist,” he fumed, “She needs a lawyer!” Dr. Hsieh and Dr. Harrison Alter went on to start the ED help desk, called Highland Health Advocates, at our hospital.
Like the other Social Emergency Medicine initiatives on my list, a help desk needs champions, and an investment of resources. Fortunately, the challenge of addressing social determinants of health is not unique to emergency medicine. It is a challenge, and frustration, shared by physicians in many specialties, and their social work colleagues, in every medical center that works primarily with underserved patient populations. These medical centers, through their departments of family practice, pediatrics, geriatrics, etc, can marshal and share resources to create help desks at their individual sites. There are now help desks located at Stanford Medical Center, San Francisco General Hospital and the UCSF Benioff Children’s Hospital pediatric ED. There is even a Bay Area Regional Help Desk Consortium to foster a regional approach, help with implementation, and share lessons learned.
To ED doctors, the idea of a help desk may seem like something more suited to a primary care clinic, the patient’s medical home. Yet we all know that, for many of our patients, the ED is the only point of contact with the healthcare system. If we don’t link them with the services provided by a help desk, it will never happen. And, when the help desk succeeds, say by obtaining a paratransit pass for your disabled patient, it increases the chances that that patient can, and actually will, make it to their primary care appointment. This could mean one less frequent flier for you. Oscar would immediately recognize it as a classic example of helping oneself by helping one’s patients.
Likewise, ED social workers – who are forced to triage their own time and often can only attend to the most immediate crises – recognize that help desks offer a more proactive approach and can focus on patients’ long-term social problems. Ezra, one of our ED social workers, tells the story of a woman whose already sketchy living situation was lost to fire. Living among drug users, and with mental health issues of her own, she had previously come to our ED many times. Ezra was able to find a short-term placement for her, but he then referred her to Highland Health Advocates. There a volunteer spent 3 hours helping her sign up for food stamps, Salvation Army Fire Relief and a Section 8 housing wait list. When Ezra checked on her progress, the patient hugged him and the volunteer and, in tears, said she felt optimistic about her future for the first time in years.
OK, so let’s say you buy this notion that social determinants of health directly underlie many ED visits. And, yeah, you are always willing to try and address your patient’s real problem, even if it’s not life-threatening. Further, let’s suppose some other far more big-hearted and ambitious colleague has actually established a help desk outside your ED. How do you know which patients to refer? Dennis Hseih gives these pointers. The first clue, often, is you find yourself wondering, “WTF? Why is this patient here?” Those are the patients whom you should then ask, “Do you have somewhere safe to stay?” and “Do you have enough money for food and for your medications?”
By making that well-targeted help desk referral, you stand to turn a “waste of your time” into a positive encounter – one that could have a lasting, beneficial effect for your patient.
In my next blog post, I’ll show you how another Social Emergency Medicine initiative, identifying opioid misuse and prescribing buprenorphine from the ED, stands to similarly transform the dreaded “drug seeker” encounter.