When we think of essential nonphysician ED staff and the roles they play in the successful management of our patients, we tend to think of nurses, nurse practitioners, physician assistants, technicians, pharmacists, patient representatives, and even transporters, housekeepers, and clerks. But we typically overlook the ED social worker, without whose efforts the modern ED would come to a grinding halt. In the early years after emergency medicine (EM) became a specialty, few, if any, EDs were staffed around the clock by social workers. This was true even in the county and municipal acute care hospitals now referred to as “safety net” hospitals.
In those days, the role of the ED social worker frequently centered around contacting the appropriate agencies for cases of child abuse and sexual assault and arranging transportation or shelter for patients who were to be discharged from the ED.
But just as the roles of EM and EDs have evolved and expanded enormously in recent decades, so too has the role of and need for ED social workers. The presence of a skilled ED social worker will almost always make it possible to safely discharge several patients a day to their homes—with arrangements made for the services and medical equipment needed—instead of admitting them to inpatient beds. Such needed services include physical and occupational therapists, visiting nurses for wound care, medication management, blood work, intravenous infusions, and meal preparation and delivery (“Meals on Wheels,” etc). Durable medical equipment needs include bedside commodes, rails, grab bars, and hospital beds. Even preventive medicine is now initiated by the ED social worker, who arranges for age-appropriate home-safety assessments and equipment installations for the increasing number of elderly who have “aged in place” in the same dwelling over many years.
As the percentage of ED patients over the age of 65—currently 18%—continues to rise during the next 40 to 50 years, the need for skilled ED social workers is increasing exponentially. There is frequently a need to temporarily relocate older discharged ED patients with families or friends when they are alone, for assessing whether a spouse or family member is capable of caring for a discharged patient at home, and even for arranging care of a pet for patients who live alone and require admission. Another way of looking at the current situation is that EDs now serve two clients—our patients and the hospital and healthcare system. Many patients who were formerly admitted to hospitals are now expected to be sent home from the ED to avoid diminishing hospital reimbursement for short-stay “observation services,” or denials. At the same time, the complex range and degree of health insurance coverage that patients have, and the scarce availability of appropriate, timely physician follow-up, are beyond the ability of an EP to deal with while continuing to care for other patients.
As the number of ED patients eligible for Medicare and Medicaid continues to rise, and the benefits are linked to changing requirements for length and type of care (“two-midnight rule” and observation services, for example), the 24/7 ED social worker has become a truly essential member of the ED staff—and now is the time to start ramping up the coverage.
Acknowledgments
We wish to thank NewYork Presbyterian/Weill Cornell Medical Center ED Social Workers, George Haskell, LMSW, and Laura Kramer, LMSW, for providing details regarding the home services and equipment they arrange for patients discharged from our ED.