Abstract
Objective
There has been increasing attention to screening for health-related social needs (HRSN). However, little is known about the screening practices of emergency departments (ED). Within New England, we sought to identify the prevalence of EDs screening for HRSN, understand the factors associated with screening, and how screening patterns for HRSN differ from those for violence, substance use and mental health needs.
Methods
We analyzed data from the 2018 National Emergency Department Inventory (NEDI)-New England survey, a survey administered to all 194 New England EDs during 2019. We used descriptive statistics to compare ED characteristics by screening practices, and multivariable logistic regression models to identify factors associated with screening.
Results
Among the 166 (86%) responding EDs, 64 (39%) reported screening for at least one HRSN, 160 (96%) for violence (including intimate partner violence or other violent exposures), 148 (89%) for substance use disorder and 159 (96%) for mental health needs. EDs reported a wide range of social work (SW) resources to address identified needs, with 155 (93%) reporting any social work availability and 41 (27%) reporting 24/7 availability.
Conclusion
New England EDs are screening for HRSN at a markedly lower rate than for violence, substance use, and mental health needs. EDs have relatively limited resources available to address HRSN. We encourage future research on the development of scalable solutions for identifying and addressing HRSN in the ED.
Introduction
Background
For over 20 years, researchers and policy makers have discussed the importance of the emergency department (EDs) as a social safety net, the “logical site” for “identification of basic social needs and the extension of existing community resources.”1 This academic framework around this dual role of acute care and population health or public health has been expanded by the expansion of social emergency medicine as a subfield.2 Multiple studies have shown that screening for social needs in healthcare settings is acceptable to patients and families3,4 and feasible5,6 However, EDs still face significant challenges in addressing the non-medical, but health-impacting, needs of their patients.7 Health-related social needs (HRSN), such as hunger and homelessness, are risk factors for ED use8–13 and poor health outcomes.14–16
Recent policy initiatives, including the Accountable Health Communities,17 and Accountable Care Organization (ACO) models emphasize the importance of addressing HRSN and provide financial incentives to do so.18,19 Currently there is wide variation across states in terms of HRSN screening tools,20–22 outcome measures23,24 and funded services.25 Recent work through the National Academy of Medicine has begun to standardize the core domains for HRSN screening to include housing, food, utilities, transportation and interpersonal safety.20
Despite the high prevalence of HRSN among ED patients, most work on screening for HRSN has come from outpatient clinic settings. A recent survey of screening in primary care physician practices found that 16% of practices were screening for five HRSN (food insecurity/hunger, housing instability/homelessness, trouble paying utilities, difficulty obtaining transportation, and experience with interpersonal violence) and 33% were screening for none.26 Although outpatient clinic providers report mixed responses about whether such screening is within their scope of work,27 one study found that provider perception of clinic capability to address social needs was associated with lower rates of burnout.28
Importance
Although there is strong interest among ED providers in addressing HRSN, many providers feel unable to act due to lack of time and knowledge.29 There have been reports of individual academic EDs developing systems to screen for HRSN in the ED,30–33 primarily focused on food insecurity, but little is known about screening programs on a broader scale, and specifically in community EDs.
Goals of this investigation
The aim of this study was to describe ED screening patterns for HRSN and to identify ED- and hospital- level factors that are associated with screening. In addition, we sought to describe how screening patterns for HRSN differ from screening patterns for violence, substance use and mental health needs.
Methods
Study Design
We conducted a cross-sectional study of all New England EDs open during 2018. The Partners HealthCare Human Research Committee reviewed this project and classified it as exempt.
Survey
We analyzed data from the 2018 National Emergency Department Inventory (NEDI)-New England survey, a 3-page survey administered to all ED directors in Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, and Vermont during 2019 about the year 2018. Methodology for the NEDI-New England surveys has been described previously34–37 and is described in detail in the Technical Appendix.
The NEDI-New England survey included questions about ED characteristics (e.g., number of ED beds), staffing (e.g., percent of attending physicians who were board-certified or board-eligible), electronic resources, consultant availability, crowding, ED policies for opioid management, and HRSN (Please see Technical Appendix for questions). This is the first year HRSN questions were included in the survey. Results of other portions of the survey will be reported separately.
The primary outcome measure for this study was performance of HRSN screening, defined as a yes to any of questions regarding screening for housing instability, food insecurity, difficulty obtaining transportation or paying for utilities. These domains were drawn from recent consensus recommendations for screening for HRSN in clinical settings.20 Violence was separated into intimate partner violence (IPV) and other violence as many EDs screen for IPV separately from HRSN, and screening for IPV has been recommended by the American College of Emergency Physicians since 2007.38 Secondary outcomes included ED screening for IPV/other exposure to violence, substance use, and mental health needs. We also collected data on social worker (SW) availability to the ED.
Analysis
We used descriptive statistics to describe and compare the characteristics of EDs who were and were not providing HRSN screening. We also used summary statistics to describe the specific types of screening, availability of social work in the ED, and co-prevalence of screening practices among EDs. There is little in the literature to guide a theoretical model of ED HRSN screening practices and the inclusion of potential confounding variables. Therefore, we present only descriptive data regarding existing screening practices in this brief report. All analyses were conducted in Stata/IC (version 15.1; StataCorp LLC, College Station, TX).
Results
Of the 196 EDs in the data set, there were 194 New England EDs open in 2018, 27 ED directors did not respond to the survey and 1 was excluded for missing responses to the questions of interest; the overall response rate was 86% (166/194), with >80% in each state. There were 64 EDs that performed any HRSN screening (39%); 102 EDs (61%) did not. (Table 1). A total of 54 EDs (33%) reported screening for housing instability or homelessness, 24 (14%) for food insecurity, 29 (17%) for difficulty obtaining transportation and 10 (6%) for trouble paying for utilities (Table 2). A total of 7 EDs reported screening for all 4 HRSNs accounting for 11% of the 64 EDs with any screening; 8 EDs (13%) screened for 3; 16 EDs (25%) for 2 and 33 (52%) for 1 HRSN. In contrast, 160 EDs (96%) reported screening for IPV or other violence exposure, 159 (95%) for IPV alone, 148 (89%) for substance use, and 159 (96%) for mental health needs. Regarding resources for responding to screening, 155 EDs (93%) reported availability of a SW, and of those 26% (41/155) reported availability 24 hours/day, 7 days per week; 32% (38/155) reported an ED based SW and 49% (81/155) reported a hospital SW that responded to the ED (Table 2).
Table 1.
ED characteristics by HRSN screening status
| Performing HRSN screening | Not performing HRSN screening | |||
|---|---|---|---|---|
| n=64 | n=102 | |||
| ED Characteristics | n | (% or median IQR) | n | (% or median IQR) |
| Median annual total ED visits (IQR) | 64 | (28,000 [14,028–49,740]) | 102 | (26,000 [14,600–48,000]) |
| ED volume categories (visits) | ||||
| 1–10,000 | 4 | (6) | 11 | (11) |
| 10,001–20,000 | 20 | (31) | 28 | (27) |
| 20,001–40,000 | 17 | (27) | 34 | (33) |
| 40,001 or more | 23 | (36) | 29 | (28) |
| Median number of ED beds (IQR) | 64 | (24 [13–33]) | 102 | (20 [12–34]) |
| Academic hospital* | 11 | (17) | 13 | (13) |
| Median % of patients arriving by ambulance (IQR) | 64 | (22 [17–30]) | 102 | (20 [16–30]) |
| Median % of patients who self-pay (IQR) | 54 | (10 [5–20]) | 95 | (9 [5–15]) |
| % of patients who self-pay (quartiles) | ||||
| 1 (0.3–5%) | 19 | (35) | 29 | (31) |
| 2 (5.5–10%) | 13 | (24) | 34 | (36) |
| 3 (11–15%) | 7 | (13) | 13 | (14) |
| 4 (17.5–80%) | 15 | (28) | 19 | (20) |
| Median % of admissions (IQR) | 64 | (20 [12–25]) | 102 | (17 [12–21]) |
| % of admissions categories | ||||
| <10% | 7 | (11) | 12 | (12) |
| 10–20% | 32 | (50) | 64 | (63) |
| >20% | 25 | (39) | 26 | (25) |
| Median % of critical care transfers (IQR) | 64 | (0.7 [0.2–2]) | 102 | (0.9 [0.2–2]) |
| State | ||||
| Connecticut | 11 | (17) | 17 | (17) |
| Maine | 10 | (16) | 21 | (21) |
| Massachusetts | 25 | (39) | 36 | (35) |
| New Hampshire | 10 | (16) | 13 | (13) |
| Rhode Island | 5 | (8) | 5 | (5) |
| Vermont | 3 | (5) | 10 | (10) |
| Urbanicity** | ||||
| Rural | 10 | (16) | 16 | (16) |
| Urban | 54 | (84) | 86 | (84) |
| Boarding in the ED | 48 | (75) | 64 | (63) |
| Median % of patients left without being seen | 64 | (1.2 [0.8–2]) | 102 | (1 [0.5–2]) |
| Capacity status | ||||
| Under capacity | 5 | (8) | 10 | (10) |
| Good balance | 22 | (34) | 24 | (24) |
| At capacity | 16 | (25) | 30 | (29) |
| Over capacity | 21 | (33) | 38 | (37) |
| Social worker availability | ||||
| ED based SW | 15 | (23) | 23 | (23) |
| Hospital SW that responds to ED | 33 | (52) | 48 | (47) |
| Mixture of ED and hospital-based SWs that respond to ED | 14 | (22) | 19 | (19) |
| Other | 0 | 3 | (3) | |
| None | 2 | (3) | 9 | (9) |
| Any SW | 62 | (97) | 93 | (91) |
| Of those with any SW, presence of 24/7 SW† | 22 | (35) | 19 | (20) |
Abbreviations: ED, emergency department; HRSN, health-related social needs; IQR, interquartile range; SW, social worker.
Data are no. (%) of EDs unless otherwise indicated. Percentages may not total to 100% due to rounding.
Academic hospital was defined as a member of the Council of Teaching Hospitals and Health Systems.
Urbanicity defined as core based statistical area (CBSA). 47
Excluding EDs who reported no availability of any Social Work Services (n=155)
Table 2.
Prevalence of screening in New England EDs
| Individual question | Composite questions | |||
| Screening Type | n | % | ||
| Housing instability/homelessness | 54 | 33 | ||
| Food insecurity/hunger | 24 | 14 | ||
| Difficulty Obtaining Transportation | 29 | 17 | ||
| Trouble Paying Utilities | 10 | 6 | ||
| Any HRSN | 64 | 39 | ||
| IPV | 158 | 95 | ||
| Other violence | 140 | 84 | ||
| IPV or other violence | 160 | 96 | ||
| Substance use | 148 | 89 | ||
| Mental health | 159 | 96 |
Data are no. (%) of EDs unless otherwise indicated. Percentages may not total to 100% due to rounding.
Abbreviations: ED, emergency department; HRSN, health-related social needs; IPV, intimate partner violence; IQR, interquartile range.
There were three EDs that did not screen for either HRSN or IPV, substance use or mental health needs. Of the EDs that did not screen for HRSN, 99 (97%) of them were screening for one or more of IPV, substance use or mental health needs. There were no EDs that reported screening for HRSN only, without IPV, substance use or mental health needs screening.
Limitations
There are several limitations to our study. We do not have detailed data about screening practices, including staff role group performing screening, how screening was operationalized, or the specific response to a positive screen. We did not record if screening was mandatory or universal. Our findings suggest that these are areas of future study. In particular, we do not have data on the specific HRSN questions being asked. Studies have demonstrated that there can be discordance between individuals who screen positive for a particular need and those who are requesting help,39 and efforts to identify HRSN may need to assess both for social risk (screening questions) and the patient report of what assistance is desired.40 Also, these data were self-reported by EDs, which may have introduced social desirability bias. The questions do not address how often screening is happening or reasons for the lack of screening, and there may be other factors associated with HRSN screening practices. Although these data provide a novel and comprehensive description of screening practices regionally, patterns in other areas of the country may differ.
Discussion
In this regional cross-sectional study of 166 New England EDs, we found that only 39% of EDs were screening for HRSN, as compared to 98% of EDs who were screening for IPV, SUD or mental health. Only 23% of EDs had an ED-based SW, although 93% reported some SW staffing.
This study provides the first comprehensive examination of screening practices across all EDs in a U.S. region, both academic and community. A prior study examined screening practices using data from hospital and physician practices (not specific to emergency medicine) in the National Survey for Healthcare Organizations and Systems (NSHOS) during 2017–2018. It found that 24% of hospitals and 16% of practices reported screening for all five of food insecurity, housing instability, utility needs, transportation needs and IPV. The majority of hospitals reported screening for IPV, followed by transportation and housing needs, with a lesser percentage screening for food and utility needs.26
With increasing regional and national emphasis on identifying and addressing HRSN, these data demonstrate that there is significant room for improvement in ED screening practices. The high rates of reported screening for substance use, mental health and IPV, suggest that ED-based screening suggest that screening for HRSN may be feasible even in busy, high-acuity, high-needs EDs. Integrating data collection for HRSN into the electronic medical record (EMR)18 may help reduce barriers to collecting information on HRSN.33
One potential challenge to successful screening is a concern about the appropriate intervention for patients who screen positive. Despite ongoing efforts to collect and systematize community health resources and link that information with the EMR41–44 many studies have reported low rates of successfully connecting patients to resources.45,46 We encourage future research focused on the development of optimal strategies for identifying and addressing HRSN in ED patients and on ensuring that such strategies are scalable across all EDs, and applicable for patients with limited English proficiency or limited access to state-sponsored resources.
Overall, these data show a relatively low prevalence (39%) of HRSN screening among New England EDs, although over 80% screen for IPV, SUD and mental health concerns. Additional work is needed to identify the optimal screening strategy for EDs with a diverse set of volume/capacity constraints and the best practices for connecting patients with the necessary resources to address identified HRSN in the ED.
Supplementary Material
Acknowledgements
We thank Rain E. Freeman, MPH; Maranatha M. Teferi, and Cordelia Zhong for their assistance with data collection and management. We would also like to thank the Connecticut College of Emergency Physicians, the Maine Chapter of the American College of Emergency Physicians, the Massachusetts College of Emergency Physicians, the New Hampshire Chapter of the American College of Emergency Physicians, the Rhode Island Chapter of the American College of Emergency Physicians, and the Vermont Chapter of the American College of Emergency Physicians for their endorsement of the NEDI-New England survey.
Funding source: This study was supported by a grant from R Baby Foundation (New York, NY). Dr. Samuels-Kalow is supported by the Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health Award UL 1TR002541) and financial contributions from Harvard University and its affiliated academic health care centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, or the National Institutes of Health.
Abbreviations
- ED
emergency department
- HRSN
health-related social needs
- IQR
interquartile range
- IPV
intimate partner violence
- SW
social worker
Footnotes
Potential Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose
Financial disclosure: The authors have no financial relationships relevant to this article to disclose
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