Challenges connecting emergency department patients with oral health care

Abstract

Background.

Unmet dental need shares many risk factors with unmet health-related social needs (HRSN) such as housing and food security and are a common cause for seeking treatment at the emergency department (ED).

Methods.

The authors recruited a purposive sample of English-speaking and Spanish-speaking patients, ED clinicians at 3 urban EDs, and dentists from nearby communities to participate in qualitative interviews to explore barriers to and facilitators of screening for HRSN and unmet dental needs in the ED. Themes were identified from transcripts using a modified grounded theory approach.

Results.

Interviews were conducted with 25 ED patients, 19 ED clinicians, and 4 dentists. Four themes were identified: (1) a preference for formalized resources, which more frequently exist for HRSN than for oral health; (2) frequent use of ad hoc resources that are less reliable or structured, particularly for dental referral information; (3) limited knowledge of oral health care resources in the community; and (4) desire for more assistance with identifying and addressing resource needs for both HRSN and oral health. Patients were amenable to screening through a variety of modalities and felt it would be helpful, but clinicians emphasized the need for easier referral processes because of frequent failure to connect patients to oral health care.

Conclusions.

More robust infrastructure and clinician support are needed to ensure successful referral and screening without undue provider burden for both medical and dental clinicians.

Practical Implications.

Patients are amenable to screening for unmet oral health needs and HRSN in the ED, which may improve access to care.

Barriers to oral health care, including lack of insurance coverage, high costs, and geographic inequities, continue to keep dental treatment out of reach for many people in the United States.¹ Instead, patients visit the emergency department (ED), although only limited dental treatment is usually available.^2,3 ED visits for dental problems increase when public dental benefits are reduced and in geographic areas where there are fewer practicing dentists who accept public insurances.^4,5 There are almost 2.5 million ED visits for a dental problem annually,⁶ and dental problems are among the most common diagnoses prompting an opioid prescription after an ED visit, although such visits do not lead to definitive treatment for dental pain.⁷ In 1 study, only one-half of patients with a dental-related ED visit were able to see a dentist within 6 months of their ED visit.⁸ People without insurance, with public insurance, with a non-English language preference, and people of color are more likely to seek care in the ED for dental problems, compounding extant inequities in oral health outcomes by racial and ethnic identity, primary language, and income.^9–11

Concurrently, health systems and payors have begun to contextualize patients’ health access and outcomes within the communities they live and patients’ ability to safely access housing, transportation, food, and other resources. Screening for these health-related social needs (HRSN) increasingly is being incorporated into health care visits. Screening for HRSN is a mandated quality metric in some accountable care organizations,¹² and the Centers for Medicare & Medicaid Services has developed an HRSN screening tool.¹³ Because unmet HRSN are associated with increased use of the ED for ambulatory care–sensitive conditions, screening for unmet HRSN can take place even in the ED setting, with patients who screen positive subsequently directed to resources.¹⁴ Although the practice is not yet universal—39% of EDs in New England reported doing so in 2019—such screening also represents an opportunity to connect patients to oral health care.¹⁴

Patients with unmet HRSN and unmet dental needs share many common risk factors and would benefit from similar postdischarge referral assistance.¹⁵ Yet little is known about how patients and medical and dental clinicians perceive the interaction of HRSN and unmet dental needs and how screening can improve patients’ access to resources for HRSN and oral health care.

The purpose of our study was to characterize barriers to and facilitators of dental referral perceived by emergency medicine clinicians, ED patients, and community dentists and to contrast these barriers and facilitators with referrals for HRSN.

METHODS

We conducted a cross-sectional study of emergency medicine clinicians, dental clinicians, and patients seeking care at an ED. We used purposive sampling for enrollment of participants. We used in-depth qualitative interviews to evaluate perceptions about connecting patients with dental resources in the community (including referrals to federally qualified health centers, dentists who accept public insurance, and dentists who do not) and resources to address HRSN. We obtained Massachusetts General Brigham and Women’s Hospital human subjects review board approval (2022P00348). Methods and outcomes reported meet the Consolidated Criteria for Reporting Qualitative Research guidelines (checklist available online).¹⁶

An interview guide in both English and Spanish was developed by researchers with extensive qualitative analysis experience and provided initial and ongoing training to interviewing research associates. Research associates conducted training interviews in both English and Spanish, and questions were refined on the basis of team feedback. Interview guides are available in the Appendix, available online at the end of this article. Interview recordings were professionally transcribed by natively fluent English or Spanish speakers. Initial interviews were reviewed as soon as transcripts were returned, and real-time feedback was provided to interviewers to enhance interview quality. Interviews were conducted from August 2022 through January 2023. Interviewers were not known to the participants before study enrollment.

Patient participants were recruited during ED visits to 1 of 2 academic EDs or to a community hospital ED within the same health system. Patients were considered eligible if they spoke English or Spanish, were assigned a triage acuity of Emergency Severity Index levels 2 through 5, and were not seeking treatment for acute mental health needs or from a carceral facility. We chose these inclusion criteria because all interviews were conducted with natively bilingual interviewers and these 2 languages represent most ED patients, because Emergency Severity Index of level 1 represents an immediate need for lifesaving intervention that would be inappropriate for participation in a qualitative interview, and because those from a carceral facility or in mental health extremis may be unable to consent. Adults 18 years and older were interviewed about their experiences; for pediatric patients older than 1 year, caregivers were enrolled and interviewed about their experiences. Interviews were conducted in person in English or Spanish by natively bilingual research associates during the patient’s ED visit. When discussing screening for unmet oral health needs, we referred specifically to a screening questionnaire, as this is commonly used for HRSN and there is established concordance between patient-reported needs and clinical findings.¹⁷

ED clinicians were considered eligible if they worked at the same EDs where patients were recruited. An invitation email was sent to all clinicians including physicians, nurse practitioners, and physician assistants working in these EDs. Interviews were conducted via phone or in person.

We considered dental clinicians eligible if they practiced in a setting that accepted Medicaid insurance. We recruited dentists through a newsletter from the state dental society and a newsletter for federally qualified health center dental directors as well as through personal emails to health center dentists within the hospitals’ catchment area. Interviews were conducted via phone.

All participants underwent a verbal informed consent process. No participants dropped out after enrollment. After the interview, a brief demographic survey was administered. All interviews were audio recorded and professionally transcribed in English or Spanish. Interviews ranged in length from 4 minutes through 28 minutes (mean, 14 minutes; median, 13.5 minutes). Each participant was interviewed once. Transcripts were not returned to participants for comment before coding, and participants did not provide feedback on our results.

We used a modified grounded theory framework for our analysis. Transcripts were coded by 3 study team members using a coding tree developed by means of consensus and with input from other team members. Both the coding tree and themes were identified from the data itself, and coding tree and thematic refinement were iterative as additional themes emerged from the interview process. Themes were selected primarily on the basis of frequency, with subthemes occasionally reflecting more novel but less frequent themes, particularly those noted by ED clinicians. Thematic saturation was determined via consensus. We performed analysis using Dedoose Version 9 (https://www.dedoose.com).

RESULTS

There were a total of 48 participants, including 25 ED patients, 19 ED clinicians, and 4 dentists. Demographics of participants from each group are displayed in Table 1. We identified 4 core themes as well as 3 subthemes. The core themes were (1) preference for formalized resources, which more frequently exist for HRSN than for oral health; (2) frequent use of ad hoc resources that are less reliable or structured, particularly for dental referral information; (3) limited knowledge of oral health care resources in the community; and (4) desire for more assistance with identifying and addressing resource needs for both HRSN and oral health. Themes and subthemes with representative quotes are displayed in Table 2. Clinicians in both the ED and dental settings more commonly emphasized that ED clinicians had a lack of time and expertise to effectively screen and refer patients in the ED, whereas patients more commonly reported insufficient screening or guidance to resources. We did not identify substantive differences in responses between Spanish-speaking and English-speaking participants.

Table 1.

Participant demographics.

CHARACTERISTIC	EMERGENCY DEPARTMENT PATIENTS, NO.	EMERGENCY DEPARTMENT CLINICIANS, NO.	DENTISTS, NO.
Total	25	19	4
Sex
Female	16	9	3
Male	9	10	1
Race and Ethnicity
Asian	1	1	0
Black	7	0	1
Latinx	8	0	1
White	13	16	3
Native Hawaiian or other Pacific Islander	0	1	0
Other	5	1	0
Declined	0	1	0
Income, $
Unknown	7	NA*	NA
< 50,000	6	NA	NA
50,000–100,000	5	NA	NA
100,001–150,000	3	NA	NA
> $150,000	4	NA	NA
Time in Practice, Y
< 1	NA	3	0
1–5	NA	5	1
6–10	NA	3	1
> 10	NA	8	2
Preferred Language
English	20	NA	NA
Spanish	5	NA	NA

^*NA: Not applicable.

Table 2.

Themes and illustrative quotes.

THEME OR SUBTHEME	ED* PROVIDER	DENTAL PROVIDER	PATIENT
Preference for Formalized Resources, Which More Frequently Exist for Health-Related Social Needs Than for Oral Health	“Social work is usually the place to go if they’re available and have the bandwidth, and then if it’s later in the day or they’re not available … I just go to [an internet resource] myself.”	“A while ago, when I first started. I used to take my cards down to the emergency room to have them [to] pass out to patients … I definitely thought it was successful when I was still trying to get a little bit busier. A lot of patients did come via that route.”	“Food and resources. [My primary care providers] have a boutique for people that need interview clothes. So I went [to their office] for that.”
	“Someone had made that list [of dentists] previously and then gave it to me, so I didn’t make it myself … It’s a public smart phrase that anybody has access to.”	“The main problem is that the most common thing in EDs is they hand patients a list of offices that take [Medicaid], but those offices almost never are taking new patients and aren’t updated … What would be amazing is for someone in the ED to actually help someone schedule if it’s during the day, to actually call an office.”	“Well, [ED staff] would have to see [screening for oral health and health-related social needs] as an expected and important responsibility that comes with their job. And my guess is most of them don’t see it that way … that has to come from a culture of an institution … I think most of the ER people think their job is to do ER work, not strikeout in broader social ways that might well be very beneficial in which they might uniquely be able to help, but they don’t see it as part of their job.”
	“Any universal screening for children in the emergency department with sort of automatic social work referrals would be really helpful because not only am I not an expert in navigating these types of issues, I also have a lot of competing demands, and I don’t have the time to ask everyone … you’re going to miss other people. Vulnerable children have all shapes and sizes, so I think universal screening is sort of the way to have a more thorough and a more thorough screening process with a social work referral as needed so that they can be connected to people who are really experts in managing these issues.”	“One of the big things I feel like I’m lacking in private practice is access to anybody’s medical record … I like to think that makes referrals and also just information-sharing a whole new ballgame.”	“I would say communicating more with [patient coordinators/community health workers.] Communicate with them and let them know, “This person is going through this, maybe you should reach out to resources,” or any of that to help them.”
Frequent Use of Ad Hoc Resources That Are Less Reliable or Structured, Particularly for Dental Referral Information	“You can tell people that they need to find a dentist, but they can’t do it because dentists aren’t out there taking patients without insurance.”	“We have started emailing and texting patients … but we still get a good amount of no-shows and people that just don’t show up for their appointments.”	“I just did my research on Google. And then I also located the dentist. I went by reviews.”
	“I can’t say that I know the stories of what happens to patients after they leave, so that part is opaque to me.”	“If someone’s Google searching for a dental practice, they’re going to find us … There’s a lot of Facebook referral happening, so people mentioning, ‘Oh, where should I go find a dentist?’ And people mention us. Occasionally, they’re referred by other dental practices.”	“[My dentist] was referred to me by my brother-in-law.”
	“[Knowing about resources is] word of mouth. A lot of people that know about it, I asked them, and this is how I most of the times end up knowing about it.”	NA†	“When I came to [Boston] … I had absolutely no idea how to find [a dentist] … So I was looking for one that might be reputable.”
	“For a while … we had a list of shelters that were open 24/7 if it was the middle of the night, but they’d changed and those don’t seem to have been updated. So when we’ve tried to call sometimes, there have often been no answers … I’ve kind of given up on those.”	NA	NA
Subtheme: structural barriers make access to dental care less successful	“Social resources are more available because the government helps. The government doesn’t help with dental, at least not the federal government. So it’s up to the goodwill of clinics for the most part.”	“We’re just at capacity. So we have about 1,700 people on the waitlist, and we always need to give priority to those existing patients waiting for cleanings, so I think we just don’t have enough times available.”	“I’ve been trying to see the dentist before, and usually the wait times are just long. So you had to schedule … out 6, 8 months, something like that.”
	“The most common thing in EDs is they hand patients a list of offices that take [Medicaid], but those offices almost never are taking new patients and aren’t updated … Just sending patients to the link on [the state’s Medicaid website] that like, ‘Find a dentist,’ that’s rarely updated too … What would be amazing is for someone in the ED to actually help someone schedule.”	“The problem with my office was we were getting so backed up with … Medicaid-type patients that we weren’t able to get people in in a timely manner. People would wait three, four months just for a filling because we were so booked up.”	“[No pude hacer cita con un dentista] porque o no contestan o no están atendiendo ahorita todavía, a menos de que sea llamadas de emergencia.” (“I could not make a dental appointment because dentists they don’t answer or they’re not in, or they’re only answering emergency calls.”)
	“I don’t think the screening is the challenge because it’s pretty simple to just ask the patient, ‘Do you have access to dental care?’ And they’ll tell you, “Yes, no, or I could, but I don’t have insurance, so I can’t afford it,” or something else … Screening isn’t the issue … it’s the access to dental care and the fact that a lot of patients have to pay for that out of pocket, and it’s not included with health insurance.”	“I think it’s easy enough to call us up and make an appointment and actually get in if they’re still motivated to do so. But sometimes, people who have extensive needs can have an extensively expensive treatment plan.”	NA
Limited Knowledge of Oral Health Care Resources in the Community	“I’m not super comfortable with [dental referrals] because … I’m not an expert, so I don’t know whether information that I have or can find is good information or the best information or up-to-date information.”	“I wish we did [receive specific referrals directly from the ED.] I think that would be great.”	“My guess is that most people who are short of money for food are not going to the dentist.”
	“There are lots of dentists around and you can just call up a local dentist and get an appointment. Whether or not you can pay for itis totally a different thing … there isn’t nearly as much information about oral health needs as there is about mental health or social issues … there are probably more dental resources, but there’s no way to pay for them.”	“I actually have an urgent care located above my office … we’ve had some referrals … between our office and them, and part of that is just simply knowing who they are. I know the doctors up there. They’ve met me. We all feel confident referring to each other … put a face to the name.”	“I think it’s also nerve wracking to switch dentists and find one that you can trust because you want someone that’s not going to tell you you need work done that you don’t need … I had to switch because I moved … there weren’t a lot of resources online … I would have liked for there to be somewhere better to go to find a good dentist.”
Subtheme: oral health needs are less prioritized than health-related social needs	“It’s easier in many ways [than referrals for health-related social needs], because … there are a lot of dental clinics in [city] and it is actually kind of easy to get follow up care with them … But as far as outpatient referrals … that’s probably one of the easier things. You give them the list, you tell them how to use the list.” “Dental needs are usually a one stop shop. Like patient needs dental care, give them some phone numbers, make them make some phone calls. The social needs is a sort of more profound all-encompassing problem. That one phone number’s not going to be sufficient and there’s no assurance. Without involving social work, there’s not much of a social there’s not much of a safety net to see if anything actually happens. Like if they don’t get dental care, they don’t get dental care … But that’s in some ways less of a true concern than the fact that they’re not able to eat on a regular basis, or they’re not able to have secure housing.”	“It’s a little harder to make sure that a new patient shows up to their appointments. We have an automated reminder system, but sometimes if a person schedules an appointment while they’re in pain and then they get treated at the ER …they might say, ‘Oh, I don’t need the appointment anymore.’” “People tell me they haven’t been to the dentist for a long time because they were scared. And when they do eventually come in, if they find out that things aren’t as they were hoping … if they do have problems … that need a lot of treatment, people will be scared. And whether that’s fear of pain or fear of the cost or fear of just the unknown, that seems to be a big barrier too.”	“No [he experimentado dolor de la boca,] pero se me cayó un diente picado, un diente careado, y todavía no ido a sacármelo. Lo tengo aquí y nada más.” (“I haven’t [experienced mouth pain,] but I had a chipped tooth, a decayed tooth, and I haven’t gone to get it removed yet. I have it here and nothing else.”) “I went to [a dental school clinic] because I don’t have dental insurance even though I work at a dentist.”
	“It would have to be a priority among all of the other competing priorities in the ED. So I’m not totally sure why I would screen for unmet oral health needs in the ED, as opposed to screening for unmet podiatry needs, or unmet primary care access, or unmet food insecurity or any of the other problems that patients face.”	“[Patients] that come through the emergency department, as soon as they’re out of pain, the majority of them don’t come back. You try to set them up for cleaning and things like that, try to get them back in the routine, but a lot of them don’t come back and only pop up when they’re in pain in the future.”	NA
Desire for More Assistance With Identifying and Addressing Resource Needs for Both Health-Related Social Needs and Oral Health	“[Providers] often just have patients stick around until social work is available, which for some people, they’re willing to do, and for some people, they’re not. And given how crowded we are, it’s not a great system to have someone just sitting around in the ED waiting to talk to the social worker for maybe 8 hours.”	“If I were the physician and I was referring patients out to dental practices, I wouldn’t know who I was referring them to … So if I had that referral pad and was just ripping off a page, saying, ‘Here, patient, here’s a bunch of dental offices. Go to one of these.’ I, as a physician, would not feel confident …. And so if there is some way for networking to happen, some way for the dentist to just connect with the ED physician somehow, I think that would make the referral process a lot more confident.”	“People sometimes are not afraid, but shy, about talking about their financial situation, if they got food or if they don’t. They just don’t want to say it. Even though they actually do need help.”
	“It’s really helpful to offload [screening] to the triage side of things, because patients are waiting anyway … Because I don’t think it takes a doctor to figure that out … And oftentimes, it leads to a delay in discharge for the patient because we’re waiting for social work to finish up at the end … So maybe doing it more at the front end and having it be someone who’s specifically triage for social needs.”	“I think it’s a good idea to have a good referral system from the ED. 99% of how to get more patients seen is that there just aren’t enough Massachusetts dentists accepting [Medicaid] … I don’t think the problem is the EDs not having the resources to refer. There’s just no one to refer them to.”	“It’s mostly everything says email or go online. Go online to pull this up … And a lot of places you can go online, but you won’t get a response at all. So it’s, what are we supposed to do?”
	“I guess the onus would probably be more on the dentist to let the hospitals know that they’re available to see patients … But I don’t think the hospitals can do any more to direct them towards dentists.”	NA	NA
Subtheme: opportunities for improvement	“I think a better global organization of our ED and having protocols that list clearly what the expectations are, and then better staff coverage so that we have the time to do these sorts of things.”	“One simple way [to improve referrals from the ED to dentists] would be … paper referrals … to reach out to the local dental offices or oral surgeon offices in the vicinity of the hospital … so that they have something to give to patients.”	“Maybe online surveys, just more like giving the patient the option to do it or not. And also the environment that they’re not pressured or answering in front of someone … Because you’re more honest by yourself[.]”
	NA	“I actually have even seen urgent care located above my office, and so I’ve done some nice networking that way … We’ve had some referrals … between our office and them, and part of that is just simply knowing who they are. I know the doctors up there. They’ve met me. We all feel confident referring to each other … Put [ting] a face to the name.”	“[Es] mejor por persona, que nos llamen a uno. Porque luego los mensajes llegan en inglés y uno ni los entiende. Otra cosa, ahora como hay tanta cosa de que están mandándole tantos mensajes … une piensa que es mentira y lo borra … Sería major que lo llamen a uno y que le digan que es de aqui que están llamando y le den la información.” (“It would be better for people if someone called us. Because often the messages come in English and no one understands them. Another thing, right now there are so many messages … that someone thinks they’re lies and deletes them … It would be better if someone called and said they were from [the ED] and gave the person information.”)

^*ED: Emergency department.

^†NA: Not applicable.

Preference for formalized resources, which more frequently exist for HRSN than for oral health

Participants favored the use of reliable, structured resources that could be more integrated into clinical workflows. An ED clinician noted that for HRSN, “We have a social worker, case manager, an addictions person, and they can help talk with the patient.” In contrast, another ED clinician stated, “Resources for social needs is largely social worker driven. Resources for dental needs is clinician driven, but we have poor knowledge.” Dentists acknowledged the existence of this gap in referral resources, with 1 dentist participant stating, “I don’t think there’s any systems in place to do things like [refer patients from the ED to a dental clinic] in our region. There should be, but there is not.”

Patients used the primary care setting as an example of a location where HRSN screening is well integrated into their care. As 1 patient stated, “When I go for my physical, they ask me questions about social anxiety, how I’m feeling emotionally … And then she will give me … something for me to check out … where I need to go, what I need to do.”

Frequent use of ad hoc resources that are less reliable or structured, particularly for dental referral information

Clinicians described developing their own resources or not knowing the accuracy of available resources. In the ED, this was met with frustration, as reflected in an ED clinician’s response stating, “When I provide people with a social work consult or a dental clinic list or a housing list, I just don’t know … what actually ends up happening.” Dentists reported a similar use of ad hoc resources to attract patients, but such attempts often were viewed as successful: “I’ll say 80% of the time, it’s word of mouth. Their friend has seen me, or family member has seen me.”

Patients described negative experiences with inaccuracies in resources or that insufficient resources led to more work for them. This was true for both high-income patients with private dental insurance and patients with fewer resources. One patient reported, “[Salas de emergencia] vienen y le dicen a uno: ‘Oh, sí, usted lleva este papel, esto, y usted va a recibir este beneficio,’ y cuando uno va a llevar el papel, es diferente, no es lo que de verdad explicaron, sino otra cosa. Porque ya me ha pasado.” (“[EDs] come and tell you, ‘Oh yes, bring this paper and you’ll receive this benefit,’ and when you go and bring the paper it’s different, it’s not true what they explained to you, it’s something else. Because that’s happened to me.”)

We identified a subtheme describing the structural barriers that make access to dental care less successful, such as lack of dental insurance and the separation between medical and oral health care systems. Even when patients are given referral information, these barriers made reaching oral health care more challenging than other resources. A patient noted, “My insurance doesn’t cover everything … It’s stressful because I have to call [my insurance], and then I have to call the dentist.” ED clinicians felt these structural barriers disincentivized screening for oral health needs in the first place, with 1 participant noting, “Screening for something for which I do not have a solution feels like the epitome of despair.”

Limited knowledge of oral health care resources in the community

Across all respondent types, comfort with oral health care referrals and resources was markedly lower than for HRSN. As 1 ED provider noted, “I feel like a social worker is at least trained in helping with the social needs, but we have nobody that can help with dental needs.” Dentists noted that patients may not even be aware of oral health resources available to them: “[One barrier for new patients] is making sure they’re eligible for [Medicaid.] Sometimes patients don’t realize they need to fill it out every year, so I’d say losing insurance eligibility or for patients who are uninsured, the cost.”

An additional subtheme was that oral health needs are less prioritized than HRSN. One patient stated, “[No visitaba a un dentista] por falta de tiempo y tal vez descuido.” (“I haven’t seen a dentist because of lack of time and neglect.”) Dentists noted that this was particularly common for patients with an acute need seeking care in the ED. “[Patients] that come through the emergency department, as soon as they’re out of pain, the majority of them don’t come back. You try to set them up for cleaning and things like that, try to get them back in the routine, but a lot of them don’t come back.” Some ED providers believed that referral to oral health care was actually more straightforward than the multitude of HRSN, which may require referral to multiple different services or supports, but that it was less important (either for the patient or provider), resulting in less successful connection to care.

Desire for more assistance with identifying and addressing resource needs for both HRSN and oral health

Respondents all expressed a wish for more support, time, and connection to address resource needs. ED clinicians noted that even for HRSN, the acuity of the ED setting made screening a challenging workflow to implement. One ED clinician stated, “It may be that having me as an attending ask these questions is inefficient.” In contrast, patients identified the benefit of screening for HRSN and dental needs in the ED setting, with 1 participant stating, “Other people would … benefit from knowing … they can reach out to, numbers, contact information [for] food resources and stuff.”

As a subtheme, all 3 types of respondents had suggestions to improve referrals for both HRSN and oral health. Dentists and ED clinicians both proposed increased personal connections to enhance oral health referral. One dentist compared ED referrals with other forms of referral: “If I’m going to refer a patient for a root canal, I have a little referral pad. I rip off a sheet, and I say, ‘Here we go. Go to this office for the root canal.’ There’s no reason the ED can’t do the same thing. I don’t know if hospitals feel like they don’t want to refer to an outside practice because they don’t know us or they’re not affiliated with us.” Patients suggested screening be provided through multiple modalities, from digital to face-to-face, emphasizing the need for flexibility and to prevent creating feelings of shame through the screening process.

DISCUSSION

In our study, patients, dentists, and ED clinicians all endorsed the value of screening for HRSN and dental needs among ED patients. Patients reported similarly low levels of awareness of both social and dental resources in the community and feeling they would derive benefit from effective, structured referral processes (eg, not just a potentially inaccurate piece of paper). Yet ED clinicians described dental referrals as being less structured and less effective than providing patients with HRSN resources.

An important finding was that all patients across the socioeconomic spectrum reported having minimal assistance with finding oral health care. Patients reported using search engines and word of mouth to find oral health care whether or not they had insurance, and there were no major differences in themes identified among Spanish-speaking and English-speaking patients. In contrast, patients with higher incomes and private insurance had limited experience with HRSN referral and screening, because they did not have HRSN. Although patients with more resources may be more successful at obtaining oral health care, challenges in the process persist.

Both ED clinicians and dentists noted that identifying ED patients in need of dental referral and ensuring they access oral health care fell outside the purview of either set of clinicians, because they are pressed for time and juggle competing priorities in busy clinical practice. Similar concerns have been expressed about HRSN screening, which have been addressed in part by adding additional roles to the health care team to facilitate this, such as community health workers and social workers. Until then, the burden may continue to fall on clinicians; 1 dentist participant even described visiting EDs for personal referrals until their practice became too busy to continue doing so. These personal connections across disciplines can address the uncertainty articulated by ED clinicians about whether their referrals are effective but may only be feasible through colocation (eg, a dental practice inside the hospital) or affiliation (eg, a health system that includes both dental and medical specialties to which patients can be referred). Yet individual clinicians participating in outreach and cross-disciplinary collaboration may be a meaningful facilitator of ED referrals.

Such care navigation also could be accomplished through technology. Near-universal access to mobile phones and smartphones can allow patients to receive information on resources (such as phone numbers and addresses) directly on their devices.¹⁸ This method may also increase the number of patients who receive resources if, as several of our patient respondents noted, patients are less likely to self-report unmet needs when screened face-to-face.

Electronic health records (EHRs) also can help close the gap in referring patients to care. For example, 1 academic health system developed an automated fall risk clinical decision support tool that identified ED patients at risk of experiencing falls on the basis of EHR data and facilitated prompt referral to a fall safety clinic without requiring additional provider input.¹⁹ Yet most EHRs cannot communicate directly with electronic dental records.²⁰ Some health systems, such as Marshfield Clinic, have developed their own integrated medical-dental EHRs to improve information transfer across disciplines.²¹ Epic (Epic Systems), the most widely used EHR, also has a dental module (Wisdom), which can allow providers to refer patients more directly for follow-up and read provider notes in the ED and dental settings.

Whereas clinicians emphasized the challenges inherent in screening for oral health needs in addition to HRSN, patients reported positive experiences of screening and referral to resources within the medical setting. This discrepancy reinforces the need for structural solutions that reduce provider burden but ensure patients have access to needed resources and referrals. Social workers are embedded routinely in EDs to assist with HRSN and could be trained further to ensure referral to oral health care.²² In some settings, community dental health coordinators have been effectively embedded in EDs to connect patients to oral health care.^23,24 When available, care navigators and community health workers also can assist patients with scheduling appointments and arranging transportation.^25,26 The adoption of mandatory oral health screening, in addition to HRSN screening, by the Massachusetts Medicaid Accountable Care Organization also represents 1 possibility, as both screening tools can be administered in varied clinical settings or digitally through patient portals. Early results from the implementation of HRSN screening show some of the challenges in data-sharing and administrative burden that need to be addressed.²⁷

Overall, HRSN screening is better established in the ED setting and medicine in general. Both patients and clinicians had more familiarity with HRSN screening as well as how to act on a positive screen (such as by referring to social work or knowing that resources were current). Even with this precedent, however, connection to HRSN in the ED can be a challenge. Given the shared risk factors of HRSN and unmet dental needs and patient acceptance of these forms of screening questionnaires when seeking care, including dental screening along with HRSN screening may be a way to increase oral health equity and provide better patient-focused care in the ED.

This study had a number of limitations. Because our sampling was purposive, there is the potential for bias from the researcher’s judgment of whom to approach. Our ED-based interviews were collected from 2 tertiary care hospitals and an affiliated community hospital in a large city and may not be generalizable to other settings. ED clinicians in our sample were primarily White, and dentists were primarily women, which may limit the diversity of the ideas included. Furthermore, challenges recruiting dentists into our study may have resulted in selection bias among those who chose to participate. The state in which we conducted the study provides a comprehensive adult dental benefit, which may restrict generalizability of reported barriers to oral health care in states where Medicaid dental benefits are similar. Lastly, interviews may be subject to desirability bias (eg, dentists reporting more positivity for accepting Medicaid or patients in the ED omitting negative thoughts about their ED experience).

CONCLUSIONS

Our qualitative interviews with 48 participants including ED patients, ED clinicians, and dentists found that, although the ED was perceived as a valuable location for screening for oral health needs and HRSN, resources and workflows for successful referral are lacking. Dentists perceive themselves to be external to the ED referral process, and both ED clinicians and dentists feel they have a lack of support for effective referral to oral health care. Our results suggest that screening for HRSN in the medical setting can serve as a model of identifying patients at risk of unmet dental needs but requires additional supports including time, technology, and provider knowledge. Subsequent research should focus on the development of robust referral systems and care navigation that is effective for patients, dentists, and ED clinicians.

ABBREVIATION KEY

ED

Emergency department.

EHR

Electronic health record.

HRSN

Health-related social needs.

NA

Not applicable.

Biographies

Dr. Simon was a resident in internal medicine, Brigham and Women’s Hospital, Boston, MA, and a fellow in medical and dental integration, Harvard School of Dental Medicine, Boston, MA, when the work described in this article was conducted. She now is an associate physician, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, and a faculty member, Harvard School of Dental Medicine, Boston, MA.

Ms. Cardenas was a research associate, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, when the work described in this article was conducted. She now is a student, Department of Physician Assistant, Rutgers, The State University of New Jersey, Newark, NJ.

Ms. Davila-Parrilla is a student, Ponce Health Sciences University School of Medicine, Ponce, PR.

Dr. Marsh is an attending physician, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, and an assistant professor of emergency medicine, Harvard Medical School, Boston, MA.

Dr. Samuels-Kalow is an associate professor, Harvard Medical School, Boston, MA, and a vice chair for research, Department of Emergency Medicine, and Patricia J. O’Malley, MD Endowed Scholar in Pediatric Emergency Medicine Research, Massachusetts General Hospital, Boston, MA.