Posts Tagged social

The Social Admission Service

courtesy jamesfischer of flickr

courtesy jamesfischer of flickr

Well, as is bound to happen in the medical blogosphere, a minor kerfuffle has erupted in response to Jesse Pines’ piece about a social admission in the WSJ last week.

In one corner, the respected internist, Robert Centor (yes, of the Centor strep criteria fame) complaining about Dr. Pines admitting an uninsured woman for a cancer workup. GruntDoc, another EP blogger, fires back across the bow that Dr. Centor hates EPs, and Dr. Centor writes back, bringing up an interesting point: why are we paying so much for social admissions? Shouldn’t we have some sort of other option for the uninsured–or the social placements altogether?

I definitely don’t want to give any ammunition to the “the uninsured get all the medical care they need” crowd, (partially because it’s simply untrue) but we all certainly admit people for primarily social–not medical–reasons. (This probably would come as a surprise to the majority of the American population, who luckily aren’t reading this blog. And thank you, our tens of readers, for keeping this such a secret.)

If you look at pretty much any disease, under “Disposition” or “Indications for Admission,” there’s always that teensy tiny little caveat of “If the patient cannot care for himself/herself,” or “Expected clinical decline upon discharge.” From the teen with PID who just won’t take the meds or follow-up to the early-demented patient without help at home, you know they’re coming in. It’s kind of like any psych diagnosis: you can be as crazy as you want to be, talking about the demons in the lightbulbs, but as long as it doesn’t affect your ability to function in your life in any way, it ain’t a disorder. The social really does matter in medicine, just like it does in psychiatry.

Probably too late to tack this on to Congress’s health care financing bill, but what the hell: I hereby propose… THE SOCIAL ADMISSION SERVICE. Dr. Centor’s right; we probably shouldn’t be spending an expensive hospital bed on patients who don’t need hospital care, but GruntDoc is right too; we can’t simply turn away people who will get lost in the system or who can’t care for themselves. So we have a social admission service. Maybe it’s a doctor, some social workers, and a case worker–some sort of “comprehensive care team” that understands there may be a few simple medical issues, but the primary issue is placement, emergency Medicaid, or some simple labs tests/imaging/procedure. Quick admit, quick dispo. Maybe they only need vital signs once a day, maybe they can eat their own food. Maybe they don’t even need to stay overnight, if they’re safe going home. We save ourselves (and our country) some money, ourselves and our colleagues some valuable time, and best, of course, help our patients out of a bad situation.

Pipe dream? Maybe. Awful, terrible idea? Certainly possible. But I’d love to hear better ones, different ones, and solutions. No one’s going to deny that our health care system is in trouble–and not just because of the uninsured, or medico-legal liability, or the aging population, or any one thing in particular–and it’s going to take creative ways to fix it. Outside the box.

Today’s hospital system is based on an acute care, acute illness model, while our patients’ diseases have become almost completely chronic. Who knows? Perhaps acknowledging that “Admit/Discharge” is a bit too binary for today’s patient is the answer that we need.

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The Emergent Social Visit

After seeing a multitude of patients who seemed to be visiting the emergency department for non-medical reasons, the nurses and I started to wonder, “What percentage of our patients are actually showing up for some underlying, non-medical reason, but we’re just not picking it up?” Sure, there’s the obvious ones–the people who say they’re depressed, or try to commit suicide–but I’m not really even counting those. Those people need emergent psychiatric evaluation and constant observation. I’m talking about the people who come to the emergency department because of some social situation or problem that’s perhaps causing some somatic complaint.

  1. How about our elderly patients who come in with chronic complaints and completely negative workups? How many are just lonely and want someone to talk to? How many are depressed? (Probably a few percent.)
  2. Or the depressed patient complaining of chest pain?
  3. Or the young woman at 3am for back pain? You sigh, ranting to your colleagues, “Why the hell are they here at 3am with that? Shouldn’t they be sleeping?” and pressing a little deeper, she’s actually been assaulted by her boyfriend and had nowhere else to go?
  4. Or the chest pain with risk factors who gets admitted, who never admits (even on direct questioning) he used cocaine except when the utox comes back positive 2 days later?
  5. Or the person with tension headaches for 3 weeks whose mother just died 3 weeks ago?

Some of these I’ve seen; some of these I’ve missed, but I can’t help but believe that we hugely underestimate (or just plain miss) how many of our patients could be grouped into this category. The incidence of “social” or “non-medical” problems is exponentially higher than any of the other things we screen for in our patients:

Imagine if 2%–or 20%!–of our patients had any of the numerous medical diseases that portend badness: diabetes, known coronary disease, kidney disease on dialysis, HIV/AIDS! (Okay, yes, I know, it really seems like my own adult population probably does have a similar incidence of diabetes, but roll with me here, people.)

But we’re absolutely terrible at picking this stuff up. Not because we’re bad people, or uncaring, or don’t know how to take a social history, or don’t want to deal with a crying patient (okay, maybe some of us). But mostly because we don’t know the patient, they may not trust us to reveal some intricate or vulnerable part of their life to a stranger, or they may feel ashamed or embarrassed. Probably also because it’s easier for us to focus on the medical–we know our differentials for RUQ pain, headache, chest pain. But most of all, because these are often diagnoses of exclusion. The patient with anxiety disorder is still allowed to have an MI; the elderly woman with belly pain can certainly have cholecystitis. But by the time all this stuff is ruled out and the person you admitted is seeing the psych consult, it’s already 100 patients later for us.

One idea that I like is a social worker/case worker for some of these people–once they’re on their third negative workup, getting someone else involved. One small study in Vancouver did this, and reduced their average “frequent-flier” visits from almost 27 visits a year to 7 visits a year. (From 616 visits total in a year for the group to 175 visits total in a year for the group.)

We can also screen for this stuff in our frequent fliers. Sure, it’s easier to say, “Oh, she’s always here, give her a GI cocktail and Tylenol #3 and she’ll feel better and want to leave,” but if we can pick something up and make the right diagnosis, we end up helping the patient and saving ourselves and colleagues another round of Maalox, Pepcid, Viscous Lidocaine and Acetaminophen with Codeine.

(In full disclosure, yeah, my father’s a psychiatrist, so I was probably subconsciously groomed to think about this stuff a little more.)

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