Safety-Net Social Work: The Imperative for Recognizing and Responding to Economic Disadvantage Among Emergency Department Patients

Background/Purpose: The association between economic disadvantage and heightened risk of morbidity and mortality is well-established. Nevertheless, the economic needs of patients in healthcare settings are often overlooked. The emergency department (ED) serves as a point-of-care for 1/5 of U.S. adults annually and is often considered the “safety- net” of the U.S. health system, particularly for those who are uninsured or disenfranchised. Unaddressed economic disadvantage can increase repeat use of ED services and decrease treatment adherence. The role of social workers in the acute healthcare setting is often limited to physician requested consults or crisis intervention; routine social risk screening and subsequent service provision are uncommon. The goal of the present investigation was to identify the current prevalence of patients self-reporting multiple domains of economic disadvantage via routine screening procedures in an urban ED population. Associations between economic disadvantage, poor self-rated health, and adverse health behaviors were explored to gain a preliminary understanding of the effect of cumulative economic distress.

Methods: This is a secondary analysis of prospective, cross-sectional survey data from a convenience sample of adult patients presenting to an urban academic ED with 59,000 annual visits. Patients voluntarily completed a self-administered Social Health Survey between May and October 2009. Five categories of economic disadvantage were studied: food insufficiency, housing concerns, employment concerns, cost-related medication non-adherence, and cost barriers to accessing physician care. Logistic regression that adjusted for the effects of demographic factors (age, gender, race, educational attainment) on the association between the cumulative number of economic disadvantage exposures (range: 0-5) and measures of self-rated and adverse health behaviors. Multiple imputation methods were used to produce correct standard errors and consistent estimates of regression coefficients for missing data.

Results: Almost half (48%) of the 1,506 respondents reported at least 1, and almost a third (31%) reported ≥2 categories of economic disadvantage exposures. We found a graded relationship between the number of categories of economic disadvantage exposure and patients' poor self-rated health and adverse health behaviors (p<.05). Compared to patients unexposed to financial disadvantage, patients who had experienced 5 categories of economic disadvantage exposures had 3-fold increase in poor/fair self-rated health, a 17-fold increase in depressed mood, a 24-fold increase in high stress, a 6-fold increase in smoking, and a 5-fold increase in illicit drug use. Patients with cumulative economic disadvantage experiences were not more or less likely to report unsafe alcohol consumption.

Conclusions/Implications: Our results suggest that ED patients are willing to disclose sensitive economic concerns in the acute health setting when given the opportunity to do so. Findings indicate that the scope of ED patient self-report of cumulative economic disadvantage is broad and its relationship to poor health status is significant. Social work professionals are uniquely qualified to work with administrators of acute care settings to design comprehensive and feasible models of routine social health risk screening and responsive system interventions. This study adds support to the imperative for broad-based interventions that address the multiple, intersecting determinants of health and connect ED patients to resources that target economic disadvantage.