Social Needs Screening in the Emergency Department: Workflow Analysis and Creating Education

Healthy People 2020 emphasizes the need to develop and transform environments, both socially and physically that improve health for everyone as one of the four main goals for the upcoming decade (Office of Disease Prevention and Health Promotion, 2020). This focus demonstrates the need to look at the impact of social determinants of health on the health and wellbeing of populations. Social determinants of health refer to the conditions of the environment where people go through life and the associated influence on health (Office of Disease Prevention and Health Promotion, 2020). These may include availability of housing, food, education, work, health care, education, and community resources among others (Office of Disease Prevention and Health Promotion, 2020). It is estimated that up to 75% of a person's health is influenced by these social factors in comparison to 25% related to genes and health behaviors (O'Brien, 2019). It is essential that the influence of social determinants of health are taken into account by healthcare providers to provide comprehensive healthcare, but the responsibility and process of screening for these social factors and making referrals to appropriate resources is not unified across the healthcare spectrum (O'Brien, 2019). Wallace et al. (2020) implemented a social needs screening, referral, and evaluation process for patients entering the Emergency Department (ED) at the University of Utah Hospital in Salt Lake City. Emergency departments are a major source of healthcare throughout the United States as they provide treatment to anyone, even if they are unable to pay and are open 24 hours a day (Hooker et al., 2018). Between 2010 and 2014, the rate of ED visits increased more quickly than population growth and the most frequent complaints were abdominal issues and mental health conditions (Hooker et al., 2018). The ED was selected for the implementation of the social needs screening due to the higher numbers of patients with low-income or no health insurance (Wallace et al., 2020). The Sincere© social needs screening tool developed by Wallace et al. (2020) assesses patients for access to transportation, healthcare services, food, utilities, housing, employment, and elder/child care and offers referrals to United Way 2-1- 1 (2-1- 1). United Way 2-1-1 is a local resource call center that is staffed around the clock with information specialists who can provide resources for housing and utilities, food, transportation, medical care, and more (Utah 211, n.d.). After implementation of the social needs screening in the ED, several barriers were identified by Wallace et al. (2020) including: selective screening of patients based on perception of registration staff, lack of comfort with asking screening questions, and difficulty in following up with patients by United Way 2-1- 1. Of the 129 patients with at least one identified need, 73 requested follow up and 32 were contacted by 2-1- 1 (Wallace et al., 2020). The difficulties with patient engagement after referral to 2-1- 1 identified by Wallace et al. (2020) are similar to other social prescribing interventions that have been implemented in other countries, like the United Kingdom. Social prescribing aims to address the social determinants of health by connecting patients with link workers who have extensive follow up interaction with people to help create action plans to meet the goals of the individual (Tierney et al., 2020). Tierney et al. (2020) identified barriers to patient engagement with link workers including: limited buy-in to the program by healthcare professionals and patients; lack of patient activation or motivation to create an action plan for change; and appropriate training for link workers. For a social prescribing program to succeed, healthcare professionals need to accept the legitimacy of the program and be willing to refer patients to it and patients need to believe that the link workers are capable of providing resources to assist them (Tierney et al., 2020). In a study where patients were followed up via telephone post spinal surgery, Skolasky et al. (2018) found that those patients with higher levels of activation were more engaged in rehabilitation therapy. Wildman et al. (2018) described the training of link workers in motivational interviewing, although there was a perception that their initial was too theoretical compared to what was seen on the job. The aim of this project is to identify pain points in the screening and referral process to United Way 2-1-1 and create educational resources for the registration staff in the Emergency Department (ED) based on the principles in the Self-Determination Theory to increase screening and referrals and encourage patient activation. Self-Determination Theory can be described by the fulfillment of autonomy, competence, and relatedness for an individual to achieve motivation and behavior change (Hanlon et al., 2019). Patients participating in study by Hanlon et al. (2019) who experienced positive changes in their quality of life noted fulfilling the needs of autonomy, competence, and relatedness. Physician residents noted a statistically significant improvement in their feelings of relatedness and improved sense of autonomy after a redesigned residency rotation based on the principles of self-determination theory in a study conducted by Miller et al. (2019). The autonomy necessary in self-determination theory can be achieved through involving patients in goal setting. In a study conducted by Stevens et al. (2017), 90% of patients who were involved in setting goals for their own involvement in rehabilitation therapies felt involved and that the goals reflected their biggest issues. These patients also rated their satisfaction with the goal setting process at a mean of 8.8 out of 10 (Steven et al., 2017). Lenzen et al. (2017) identified five steps to implement goal setting with patients, which include: preparation, formulation of goals, formulation of action plan, coping planning, and follow-up. A potential method to develop training for the ED registration staff would be an e-learning module similar to one created by Simpson (2019), who implemented a didactic lesson plan which increased the knowledge of nursing staff related to patient engagement and can be adapted into a e-learning module to allow staff to review at their discretion.