How did you get involved in social emergency medicine?

That’s kind of a career long question. I became interested in the importance of social factors in emergency care pretty much from the time I discovered emergency medicine, which was as a third year medical student. Social EM didn’t exist yet as a field, so I continued to try to pursue, from both a practice standpoint and a research-and-advocacy standpoint, reinforcing the importance of social factors in the way we provide care in the emergency department.

Then, in 2008 or 2009, in talking to Andy Levitt’s family about recognizing his lifelong contribution to EM and EM research, is when Barry Simon and I decided to create the Levitt Center for social EM. Which is, to my understanding, when social EM became a field. We created the Levitt Center (http://www.levittcenter.org/) to promote research in social EM and to support people like us who wanted to do the work in the realm of social drivers to care. We wanted to give people like us an intellectual home.

Have you had any challenges in social emergency medicine that you think could be instructive for others working in the field?

There are challenges every day in social emergency medicine. Partly because it’s a synthetic process, and getting two disparate worlds—or actually really an infinite number of disparate worlds, depending on how you define the social milieu—to synthesize is always going to be a challenging process. Sometimes you engage with a community partner and the distance is too great to traverse and it’s really hard to come to a common understanding of how we can work together with our patients.  

But in general, the take home message is you have to get to know, understand, and respect your community partners. Because we can’t do social emergency medicine on our own in the emergency department: it’s too fast. There are people already who are doing the work that our patients need, but we have the patients. And so if we provide access to our patients, community programs can essentially harvest high yield patients for their social initiatives from our high needs patients. And both organizations and both populations are the better for it.

A lot of our colleagues maybe don’t focus on social emergency medicine but they want to help, and they want to do something, so if you’re able to create a resource that’s easy for them to direct patients to they will.

That’s exactly right. We talk a lot in social EM about making the right thing to do the easy thing to do.

How would you recommend others get involved in social emergency medicine?

To a certain extent, it’s like many sports: you just have to drop in. There’s no way you can sufficiently prepare before you get involved. Just get started. Contact your social workers—see if they know of any community programs that might benefit your patients.

But from a more systematic standpoint, there are a couple of steps that I recommend, particularly if you are alone in your department, or if there are maybe one or two other clinicians who are interested in embracing social emergency medicine in their practice. One way that people have found to get started is that almost every community has an eager young person who wants to go to medical school, and they’re looking for opportunities—hire that person to spend the summer in your emergency department, and do a couple of days of 24/7 surveillance. Doesn’t have to be day after day, but just over the course of the summer, spend a few nights in the lobby, a few days in the lobby, a few evenings and weekends, and survey what the social needs are in your community. When you find what the most prominent social needs are, then you’ll have a sense of who to seek out to be your community partner for your first initiative. And you’ll also have a much fuller understanding of the challenges your community faces. You may not have known for example that 25% of your patients face hunger sometime during the month. I certainly had no idea that, even though I worked at Highland for 18 of the last 25 years, 50% of our patients are food insecure, until I did a survey.

So that’s one way to get started. The other way of course is through organized emergency medicine. The Society for Academic Emergency Medicine Social EM and Population Health Interest Group (insert link here) is a very energetic group of people, and generous with their time. The same is true of the ACEP Social EM section (https://www.acep.org/how-we-serve/sections/social-emergency-medicine/). People are very willing to share experiences. We’re going to try to start structuring those experiences in meetings to facilitate that sharing. And EMRA now has a formal subcommittee for Social EM for medical students and residents to get involved (https://www.emra.org/emresident/article/social-emergency-medicine-its-what-we-do/).

What do you think the future of social emergency medicine looks like?

Well, now you’ve struck my evil plan, I was trying to keep it hidden. [Laughs]. I want social emergency medicine to go away in 25 years. Emergency medicine is not that old—depending how you date it, we’re about 50 years old. So we’re still relatively plastic. We’re known to be the specialty that can turn on a dime. For example, we reconfigured our entire triage process to accommodate Zika, and all of our infection control procedures were revised in the face of Ebola. We are very nimble, we are plastic, we are malleable, we can change. We recognize when it’s important to change. Given that we’re young and we’re nimble, I don’t think it’s too much to ask that over the next 20 or 25 years we transform emergency care to be defined by how we address social factors. And so, in 20 or 25 years “social” emergency medicine will cease to be, because it will be the practice of emergency medicine.

Where do you see the biggest changes that will help that happen? Is it legal advocacy? Is it training and education?

We have to push on all those buttons at once. There are some places where reimbursement is an issue; mostly this is just a process of recognition. It’s not really a lot of intervention on our part. But developing relationships with community partners, facilitating articulations with their services, is a big part of social emergency medicine. For example, if you want to hire health coaches in your ED you have to figure how to

bill for them. And that’s doable. I don’t think there’s a lot of stuff we have to fight for reimbursement on, but I’m sure we’ll uncover stuff as we move forward. Education is a big part of it, but I think that, with a little more research to confirm this, we will be able to prove that providing tools to clinicians to address social factors reduces burn out. I think once we’re able to show that definitively, really we will have an open field ahead of us…Once we have the medical stuff pretty well managed, all is left are these enormous social factors, which are daunting. But we’re up to the challenge.

Is there anything else you want to share with our audience?

Well, when we organized social emergency medicine, we didn’t create the work: the work had been done by investigators and advocates going back since the birth of emergency medicine. And it continues to be done by people who have no affiliation or association with the field of social emergency medicine. What we’ve been able to do over the last 10 years is, for people who seek a community in this field, provide that strength-in-numbers-feeling for people who previously felt isolated. The growth of organized social emergency medicine has provided so much power to individuals who now have connections and are involved in multi-site initiatives and are talking to one another across state lines and across neighborhoods. It’s just been such a powerful and gratifying development. I’m really excited to watch it grow.

Can you tell me about the Health Advocates program and what it was like to start it?

The Health Advocates program is a help desk for health-related social needs. It’s modeled roughly on the health leads program, but with a couple of local modifications that made it more appropriate for our uses. HA was created by a team led by three EM interns at the time, and a medical student…and they are all out changing the world. There were other help desks getting started at the same time in the Bay Area, and so we formed a regional consortium of help desks in which we supported one another and helped one another trouble shoot navigate difficult pain points in the process of launching this kind of thing. Ours, I think, was the first that was available primarily to emergency department patients—that was one of our local modifications—and it was among the first to have an integrated medicolegal partnership (MLP), along with one our consortium partners at Children’s [Hospital of Oakland]. 

MLPs have been around for a long time, but they had not really been formally integrated into the function of a help desk. So basically, an emergency department patient who is facing a social challenge—something happening out in the life that occurs in the 99% of the time that they are not an ED patient but they are just a person in the world that drives them to seek emergency care—that can be ameliorated by social intervention. Either by a social worker or a lawyer—whether it is benefits eligibility, or substandard living conditions, or lack of access to transportation, or cannot get a specialist referral—these are the kinds of things that our help desk volunteers can help patients navigate through, and teach them how to use the tools that they are using so that they may not need the help desk the next time.

What kinds of benefits have you found the help desk has had?

Well…when we first created it, it was called the Highland Health Advocates, but all the other venues in our health system became jealous [laughs], and so we expanded very quickly into all the other hospitals and most of the clinics in the Alameda Health System, so we lopped the “Highland” off the name and just made it the Health Advocates Program.  

What is particularly impressive about the Health Advocates Program I think is that it has become a community resource: it is no longer a resource that strictly belongs to the hospital. I have heard from families who have been helped who never have seen a doctor at Highland. They found the Health Advocates on the Internet, or in chat rooms, and they contacted our volunteers and our volunteers were happy to help them. And I have talked to families that have found housing for elder family members; I have talked to families that have had apartment upgrades due to the intervention of the Health Advocates that never were Highland patients. I am not sure if Alameda Health System would want to advertise that, but I’m proud of it. That we have become a resource for our community.

I think it is very important that hospitals recognize they are members of the community, that they have these enormous resources that can be brought to bear to actually improve conditions in their community, and not just provide medical care to “treat and street” members of the communities that they reside in…really, to be good citizens in their communities, and to share their resources with the society around them.

What is an interesting project you are working on currently?

There are so many! I have gotten excited lately about behavioral prescribing. I discovered a paper probably 20 years ago about a physician who was using peer support groups to address homelessness. He found that, although he did not increase housing rates among the participants in the peer support groups, he did increase retention in housing at 1 year, which is one of the really sticky things in homelessness—finding the right fit in terms of housing options for people who have been chronically homeless. So it has been known for a long time that social isolation contributes to the severity of homelessness, and that efforts around that will help you. So I have been working with a program here that does wraparound behavioral prescribing programs for clinics. They do a cohort-based model, which takes care of the social isolation piece. And in these cohorts, they do movement, they do education and training around healthy eating, they get a food box. So they address risk factors for chronic disease, like diabetes and hypertension, and they address the social isolation piece through the cohort-based model. They get peer support. And if we’re successful in bringing it to the emergency department we are hopefully going to bring in a pharmacist as well. I am excited about trying to bring behavioral prescribing to the emergency department. I would love to be able to walk a patient with chronic disease out to one of our conference rooms in the evening and introduce them to the peer support coach and say “here’s your new hospital family and we’ll see you here next Tuesday.” So we are trying to get that launched, we haven’t yet. But I think for so many reasons it would be really a marvelous thing to try.