THRIVE-ing in the Boston Medical Center Emergency Department

Authors: Emily Anderson MS4 and Jessica Lin MS4

Editors: Haeyeon Hong, MD and Gabrielle Jacquet, MD, MPH

The Emergency Department (ED) is often described as a revolving door: an analogy referring to patients returning after being “treated and streeted.” The reasons why patients return for medical care are complex and often rooted in unmet social needs, such as unstable housing or food insecurity. Studies have suggested that such unmet social needs are directly correlated to negative health outcomes[1] and to increased ED visits.[2],[3] Additionally, this excess ED utilization contributes to the nation-wide ED overcrowding and increased unnecessary health care spending.

Boston Medical Center (BMC) is an urban, academic safety-net hospital with over 130,000 annual visits, and serves a diverse patient population, including immigrants, refugees, asylees, and communities of color. At BMC, 32% of patients do not speak English as a primary language, and 72% of ED visits are associated with patients from the surrounding underserved communities.[4] The socioeconomic disadvantage faced by these communities is the result of hundreds of years of systematic oppression through racial discrimination and unjust public policy such as historic red-lining and disparaging immigration laws. As a result, health disparities due to unmet social needs are particularly salient at BMC.

As medical students, we have already begun to observe patient after patient presenting to the ED for health conditions closely linked to their social needs. We have seen patients with congestive heart failure return to the ED repeatedly struggling to breathe as their lungs fill with fluid because they were not able to pick up their medications at the pharmacy due to working multiple jobs to support their families. Elderly individuals sit exhausted in waiting rooms, clutching their metal walkers after commuting for hours on buses to come to the hospital for their 20-minute primary care appointment. As one ED patient suffering from painful abscesses caused by intravenous drugs described, “You don’t know what it’s like, not to have a home, a bed to sleep in, or a refrigerator of food waiting for you at home. Why else do you think I use drugs?”

Treating medical complications of persons who inject drugs (PWID) in the ED is important, but, as our patient illuminated us, without addressing the root causes of unmet social needs, their skin infections will persist, and so will their substance dependence. Due to the Emergency Medical Treatment and Labor Act (EMTALA), EDs serve as the ultimate safety-net resource for anyone who seeks help for a myriad of problems, most often medical or behavioral but frequently social. While we feel privileged to serve our patients in the ED at their most vulnerable moments, we can’t help but notice the burden that the department and the staff are faced with due to overcrowding, which is often related to recurring ED visits due to unsolved structural deficits leading to unmet social needs.

In outpatient settings, social risk screening and referral programs have been shown to improve linkages with community resources and decrease healthcare utilization.[5] Within BMC ambulatory clinics–including general internal medicine, family medicine, pediatrics and OBGYN–patients are routinely assessed for unmet social risks as part of an institution-wide initiative called THRIVE.[6] After the screening, patients are provided with resource guides that can serve as initial connections to the appropriate community organizations.

The success of outpatient THRIVE screening and referral progressively increased interest in expanding the program to the ED. Due to the nature of the ED as a safety net serving a particularly disadvantaged population[7], an ED-specific screening program has the potential to recognize and address unmet social needs for vulnerable patients who may otherwise lack access to higher barrier-to-entry outpatient clinics.

In 2020, work expanding the program to the ED began. However, program expansion was not a simple copy-and-paste fit. In order to accommodate the ED’s unique workflow and higher acuity level of care, several adaptations were needed.

Of the original eight social need domains screened for in primary care, five domains were chosen for ED screening: housing, food insecurity, employment, ability to pay utilities, and transportation. Rather than a paper-based program, electronic health record (EHR) based verbal screening was used. For initial program rollout, patients were deemed eligible if covered by the hospital’s Accountable Care Organization (ACO), a network of hospitals and healthcare providers that seek to provide high quality coordinated care, specifically including uninsured patients.[8] ACOs are a new type of health insurance model, currently being implemented and tested within Medicaid and Medicare, that is designed to shift the burden of rising healthcare costs and quality care from patients to providers and their hospital networks through financial incentives tied to provider performance on spending and quality targets.[9]

In September 2020, THRIVE screening began in the BMC ED. When eligible patients present to the ED, the triage staff asks the THRIVE screen questions provided in the patient’s chart while taking down the patient’s basic information and reason for presentation. Patient responses are noted in the patient’s EHR. Patients screen positive if they indicate that they struggle with any of the five social domains detailed above, and are then given a resource guide for their unmet social needs, which is automatically printed and provided by ED staff with the regular discharge paperwork.

A longitudinal quality improvement program is currently underway to assess program implementation. Preliminary findings have identified a high burden of unmet social needs among ED patients, with over 1 in 4 patients (27%) screening positive for at least one unmet social need. In follow-up interviews, patients have been unanimously supportive of the program. In response to several implementation gaps identified between screening and successful referral to community resources, further workflow optimization is in progress.

By addressing the root causes of adverse health outcomes and repeat ED visits, BMC’s THRIVE program aims to slow the revolving door. Now, with the COVID-19 pandemic leading to even further health disparities among already disadvantaged communities, programs like THRIVE that treat the ‘causes of the causes’ of inequality are more important than ever.

[1] Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep Wash DC 1974. 2014;129 Suppl 2:19-31. doi:10.1177/00333549141291S206

[2] Ku BS, Scott KC, Kertesz SG, Pitts SR. Factors associated with use of urban emergency departments by the U.S. homeless population. Public Health Rep Wash DC 1974. 2010;125(3):398-405. doi:10.1177/003335491012500308

[3] Rodriguez RM, Fortman J, Chee C, Ng V, Poon D. Food, shelter and safety needs motivating homeless persons’ visits to an urban emergency department. Ann Emerg Med. 2009;53(5):598-602. doi:10.1016/j.annemergmed.2008.07.046

[4] https://www.bmc.org/sites/default/files/For_Medical_Professionals/BMC-Facts.pdf.

[5] Berkowitz SA, Hulberg AC, Hong C, et al. Addressing basic resource needs to improve primary care quality: a community collaboration programme. BMJ Qual Saf. 2016;25(3):164-172. doi:10.1136/bmjqs-2015-004521.

[6] Buitron de la Vega P, Losi S, Sprague Martinez L, et al. Implementing an EHR-based Screening and Referral System to Address Social Determinants of Health in Primary Care. Med Care. 2019;57 Suppl 6 Suppl 2:S133-S139. doi:10.1097/MLR.0000000000001029.

[7] Fraimow-Wong L, Sun J, Imani P, Haro D, Alter HJ. Prevalence and Temporal Characteristics of Housing Needs in an Urban Emergency Department. West J Emerg Med. 2020;22(2):204-212. doi:10.5811/westjem.2020.9.47840.

[8]https://www.mass.gov/service-details/boston-accountable-care-organization-in-partnership-with-bmc-healthnet-plan.

[9] An Overview of Medicare. Kaiser Family Foundation KFF.org. Published February 2019. Accessed March 30, 2022. https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/