The Hospital Emergency Department as a Social Welfare Institution,☆☆

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Abstract

In an era of social welfare reform marked by the erosion of a societal safety net, few institutions remain that can guarantee assistance to those most in need. The hospital emergency department is perhaps the only local institution where professional help is mandated by law, with guaranteed availability for all persons, all the time, regardless of the problem. Although the ED serves as a true social safety net, its potential as a social welfare institution generally goes underestimated, hampering its full development as an effective societal resource. More of the disadvantaged may pass through the ED than through any other community institution, making it a logical site not only for the treatment of acute illness, but also for the identification of basic social needs and the extension of existing community resources. By helping more fully incorporate the ED into the total care of its community, emergency physicians can become leaders in the design and implementation of integrated sociomedical systems of care. [Gordon JA: The hospital emergency department as a social welfare institution. Ann Emerg Med March 1999;33:321-325.]

Section snippets

INTRODUCTION

The hospital emergency department holds a special position in American society. Easily accessible and always open, the ED is one of the few institutions available to help all persons, all the time, without reservation. Such a guarantee of assistance is so important that it has been enshrined in a federal law requiring EDs to evaluate everyone seeking care.1 Yet, despite the immense social power inherent in such an arrangement, most physicians and civic leaders see the ED as a purely medical

EMERGENCY DEPARTMENTS IN AN ERA OF REFORM

EDs are busier than ever, with ED visits in the United States rising to more than 90 million per year.2 Canada’s single-payer system has not curbed ED visits, which increased 6% per capita in that country between 1985 and 1990.3 Managed care did not reduce ED visits among New York City Medicaid beneficiaries,4 nor did improved primary care access eliminate preferential ED use among disadvantaged children.5 Although Medicaid beneficiaries and the uninsured are already overrepresented in the ED,6

THE HEALTH AND WELFARE OF THE DISADVANTAGED

The ED may remain the only site “where the most disenfranchised can be reached,”10 but most EDs, like other parts of the health care system, have not assumed responsibility for the “social care” of the disadvantaged. Some community clinics had previously used Medicaid reimbursement to finance social and health service coordination for the poor,11, 12 but competition for managed care contracts will likely force many clinics to scale back such assistance.13 Some health maintenance organizations

THE SOCIAL ROLE OF THE EMERGENCY DEPARTMENT

What can the ED do for the social care of the disadvantaged? Perhaps one answer lies in a comprehensive system for social screening, evaluation, and service coordination, a system designed to work in conjunction with emergency medical care. The ED could establish a “social triage” center of sorts, to which ED patients identified with pressing social needs could be referred for screening evaluation and service coordination, using preexisting community resources. The social triage center would be

SOCIAL CARE AS A PUBLIC SERVICE AND PROFESSIONAL RESPONSIBILITY

Some have suggested that intensive social intervention in the ED can decrease hospital utilization rates,39, 40, 41 but evidence of cost savings is far from definitive. Although social programs such as nutritional assistance and Head Start have shown tangible benefits,11 the impact of comprehensive social screening, referral, and service coordination in a broad community population remains unproved. Research is currently under way to evaluate the economic effect of an ED-based program for

References (45)

  • E Bernstein et al.

    Project ASSERT: An ED-based intervention to increase access to primary care, preventative services, and the substance abuse treatment system

    Ann Emerg Med

    (1997)
  • Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (PL 99-272, 42 USC, 1395dd,...
  • LF McCaig et al.

    National Hospital Ambulatory Medical Care Survey: 1996 emergency department summary

  • G Fortin

    Health Information Division, Policy, Planning and Information Branch, Health and Welfare, Ottawa, Canada, 1992; cited in Weil T: Clinton’s health reform and emergency department volumes: a return visit [editorial]

    Ann Emerg Med

    (1993)
  • JE Sisk et al.

    Evaluation of Medicaid managed care: Satisfaction, access, and use

    JAMA

    (1996)
  • RF St Peter et al.

    Access to care for poor children: Separate and unequal?

    JAMA

    (1992)
  • US General Accounting Office

    Emergency Departments: Unevenly Affected by Growth and Change in Patient Use

  • US Census Bureau

    Current Population Survey

    (March 1997)
  • GP Young et al.

    Ambulatory visits to hospital emergency departments: Patterns and reasons for use

    JAMA

    (1996)
  • The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 ; analysis prepared by the American Public...
  • E Bernstein et al.

    A public health approach to emergency medicine: Preparing for the twenty-first century

    Acad Emerg Med

    (1994)
  • J Currie

    Welfare and the well-being of children

  • PA Buescher et al.

    An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina

    Am J Public Health

    (1991)
  • M Schlesinger

    Paying the price: Medical care, minorities, and the newly competitive health care system

    Milbank Q

    (1987)
  • CBS Evening News

    Eye on America

    (January 9, 1997)
  • PJ Kenkel

    Legislation extends SHMOs through ‘97

    Modern Healthcare

    (1993)
  • SA James et al.

    Socioeconomic status, John Henryism, and hypertension in blacks and whites

    Am J Epidemiol

    (1987)
  • A Geronimus

    The weathering hypothesis and the health of African-American women and infants

  • PH Wise et al.

    Racial and socioeconomic disparities in childhood mortality in Boston

    N Engl J Med

    (1985)
  • P Newacheck

    Poverty and childhood chronic illness

    Arch Pediatr Adolesc Med

    (1994)
  • M Weinberger et al.

    Does increased access to primary care reduce hospital admissions?

    N Engl J Med

    (1996)
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    Address for reprints: JamesA Gordon, MD, MPA,Department of EmergencyMedicine, University of MichiganHealth System, 6312 Medical Science Building I, 1150 West Medical Center Drive, Ann Arbor, MI 48109-0604;313-647-4844, fax 313-647-3301;E-mail [email protected].

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