Health-Related Social Risks Versus Needs in a Pediatric Emergency Department.

INTRODUCTION: Health-related social problems may be conceptualized as the presence of either a social risk (i.e., food insecurity as defined by a screening tool) or a social need (i.e., desire for referral to a food program). Identification of social risks may not correlate with patients' desire to receive help. This study aimed to identify and compare patients and families with social risks versus social needs in a pediatric emergency department. METHODS: This was a planned secondary analysis conducted in 2023 of a previously published prospective intervention study, which screened and referred caregivers and adult patients for health-related social problems in an urban tertiary pediatric emergency department between May 2019 and October 2020. Participants completed a screening tool for social risks and self-identified social needs by selecting desired assistance from a list of social service categories. Participants' social risk screening results were compared with their selection of resources for social needs across demographic and socioeconomic characteristics and the number of positive social risks using chi-squared or Fisher's exact tests. RESULTS: Of 258 participants, 42.2% (109) screened positive for any social risk, and 38.0% (98) self-selected a social need. Of those, only 59.2% (77/130) both screened positive and self-selected a need. Among those who screened positive for a social risk, several demographic and socioeconomic factors including race, ethnicity, and income were significantly different between those interested versus not interested in assistance. CONCLUSIONS: Both social risks and self-identified social needs should be considered within social care interventions in the pediatric healthcare setting.

Management of pediatric toxic ingestions in the emergency department.

Pediatric ingestions present a common challenge for emergency clinicians. While findings and information from the physical examination, electrocardiographic, laboratory, and radiologic testing may suggest a specific ingestion, timely identification of many substances is not always possible. In addition to diagnostic challenges, the management of many ingested substances is controversial and recommendations are evolving. This issue reviews the initial resuscitation, diagnosis, and treatment of common pediatric ingestions. Also discussed are current recommendations for decontamination and administration of antidotes for specific toxins.

Community-Academic Advocacy to Improve Shelter Access for Families Experiencing Homelessness.

ABSTRACT: A 2012 Massachusetts shelter eligibility regulation required many families to spend a night in a location "not meant for human habitation" before qualifying for the state-run shelter system, and many families experiencing homelessness stayed in pediatric emergency departments (EDs) overnight to meet this requirement. ED clinicians initially recognized an increase in ED visits for homelessness after this regulation and began compiling and sharing stories with key institutional and community partners and stakeholders. To bolster advocacy efforts, the authors collected data on the magnitude of the problem and its associated health care costs. Guided by the policy knowledge of community partners, the authors leveraged the expertise and advocacy power of clinicians to share these data and stories with legislators via written and oral testimony, community events, and the media. Academic publication lent additional credibility and exposure to their research. In 2019, the Massachusetts Legislature passed budget language to overturn the 2012 shelter eligibility regulation. However, despite this policy victory, some families continue to present to EDs for homelessness. Therefore, current advocacy efforts have shifted focus toward implementation and enforcement of the new policy, monitoring issues, and developing new programmatic responses. In this advocacy case study, we illustrate how clinicians have unique abilities to serve as effective advocates for social policy change using a framework of strategies including storytelling, coalition building, tailored communication, and data sharing. Partnering with existing advocacy networks within their institution and community enhances the advocacy efforts of all stakeholders to influence social and health outcomes for children and families.

Mobile Social Screening and Referral Intervention in a Pediatric Emergency Department.

OBJECTIVE: Many families in pediatric emergency departments (PED) have unmet social needs, which may be detected and addressed with the use of a digital social needs intervention. Our objective was to characterize the feasibility and effectiveness of utilizing personal phones or a PED tablet for screening and referral to social services. METHODS: We conducted a prospective single-arm intervention study using a convenience sample of caregivers and adult patients in an urban PED between May 2019 and October 2020. Participants chose either their personal phone or a PED-provided tablet to use an app, "HelpSteps." Participants self-selected need(s) then referrals to service agencies. Participants completed a 1-month follow-up. Clinicians were surveyed about screening and impact on visit. RESULTS: Of 266 participants enrolled, 55% of participants elected to use their personal phone. Of all participants, 67% self-selected at least 1 health-related social need; 34% selected 3 or more. The top 3 "most important" needs were housing (14%), education (12%), and fitness (12%). At one month follow-up, 44% of participants reported their top need was "completely" or "somewhat" solved. For 95% of encounters, clinicians reported the intervention did not increase length of stay. CONCLUSIONS: A mobile social needs intervention was feasible and effective at identifying and referring participants in the PED setting. While more than half of participants used their personal phones, several smartphone owners cited barriers and elected to use a tablet. Overall, participants found the app easy to use, appropriate for the PED, and the intervention had minimal impact on clinical flow.

Increasing inclusivity in patient centered research begins with language.

Emergency departments frequently serve marginalized populations. Spanish-speaking families who come to the ED often have high rates of unmet social needs. Our study investigated how to efficiently screen families for unmet social needs in an emergency department. Participants who screened positive for needs were referred to geographically convenient, community-based resources. It became clear that barriers related to language discordance existed for recruiting Spanish-speaking participants that were not present for English-speaking participants, which we believe exacerbate existing inequities and must be addressed. We advocate for the extension of the Affordable Care Act Section 1557 to mandate expanded teams of interpreters to meet both clinical and research demands in conjunction with purposeful hiring of multilingual research assistants, along with concerted effort to standardize the certification process for multilingual staff. Prohibitive costs for the translation of written research materials need to be decreased and journals should evaluate submitted research with a language equity lens, which will help the field of clinical research prioritize inclusivity and diversity in research populations. Currently, systemic barriers complicate enrolling research participants who speak a language other than English, and we believe the proposed changes are feasible solutions to overcome these obstacles. Equitable representation in research is a critical part of addressing the legacy of oppression and exclusion within healthcare systems. Language equity is not a panacea for the distrust and systemic racism patients of color experience within our healthcare system that often prevent participation in clinical research, but it is a key first step.

Pediatric Emergency Department Visits for Homelessness After Shelter Eligibility Policy Change.

BACKGROUND AND OBJECTIVES: In 2012, Massachusetts changed its emergency shelter eligibility policy for homeless families. One new criterion to document homelessness was staying in a location "not meant for human habitation," and the emergency department (ED) fulfilled this requirement. Our aim for this study is to analyze the frequency and costs of pediatric ED visits for homelessness before and after this policy. METHODS: This is a retrospective study of ED visits for homelessness at a children's hospital from March 2010 to February 2016. A natural language processing tool was used to identify cases, which were manually reviewed for inclusion. We compared demographic and homelessness circumstance characteristics and conducted an interrupted time series analysis to compare ED visits by homeless children before and after the policy. We compared the change in ED visits for homelessness to the number of homeless children in Massachusetts. We analyzed payment data for each visit. RESULTS: There were 312 ED visits for homelessness; 95% (n = 297) of visits were after the policy. These visits increased 4.5 times after the policy (95% confidence interval: 1.33 to 15.23). Children seen after the policy were more likely to have no medical complaint (rate ratio: 3.27; 95% confidence interval: 1.18 to 9.01). Although the number of homeless children in Massachusetts increased 1.4 times over the study period, ED visits for homelessness increased 13-fold. Payments (average: $557 per visit) were >4 times what a night in a shelter would cost; 89% of payments were made through state-based insurance plans. CONCLUSIONS: A policy change to Massachusetts' shelter eligibility was associated with increased pediatric ED visits for homelessness along with substantial health care costs.

Trends in Homeless Children and Young Adults Seeking Shelter in a Boston Pediatric Emergency Department Following State Housing Policy Changes, 2011-2016.

OBJECTIVES: To describe a trend in emergency department (ED) use by homeless children and young adults before and after a state housing policy change in 2012 and to quantify financial and time costs to the health care system. METHODS: We retrospectively reviewed de-identified electronic medical records of homeless children and young adults aged 0 to 21 years seeking shelter at an urban tertiary pediatric ED in Boston, Massachusetts, between September 1, 2011, and August 31, 2016. RESULTS: We identified 1078 visits for homelessness by 916 children and young adults. The median number of visits per month increased from 3 before the policy change to 17 after (P < .001). The total hospital charges were $578 351, with a net payment of $214 231, 97% paid by Medicaid. The average length of stay was 8 hours, totaling more than 8500 hours of occupancy. CONCLUSIONS: The number of homeless children and young adults who visited a pediatric ED increased significantly following a housing policy change, leading to substantial resource burdens on the ED and Medicaid. Public Health Implications. Policymakers should consider potential health care costs when designing housing policies and consider investing in housing to prevent unnecessary ED visits.

Emergency department-based health insurance enrollment for children: does linkage lead to insurance retention and utilization?

OBJECTIVES: Although 40% of emergency departments (EDs) report having an insurance linkage program, no studies have evaluated the long-term success of these programs. This study aimed to examine insurance retention and utilization by children initially referred to insurance by our ED insurance linkage program. METHODS: We retrospectively examined insurance records of all uninsured children successfully enrolled in public insurance by the insurance linkage program established in our suburban academic ED between 2004 and 2009. Emergency department-enrolled children were matched by age, sex, program, and year of enrollment to a control group of children from the same county who were enrolled in non-ED settings. Wilcoxon signed rank and χ tests were used to compare enrollment and claims variables. RESULTS: Emergency department-enrolled children retained insurance for longer, had a higher reenrollment rate, and were higher users of insurance. The average length of enrollment for ED children was 734 days versus 597 days in the control group. Eighty percent of the ED cohort reenrolled in insurance after initial eligibility expiration versus 64% of the control group. Children enrolled via the ED averaged 26 claims (vs 12 claims) and $20,087 (vs $5216) in hospital charges per year of enrollment. This higher utilization was reflected in increased primary care, specialty care, ED visits, inpatient, and mental health claims in the ED group. CONCLUSIONS: Emergency department-based insurance enrollment programs have the potential to improve access to health care for children. Policies aimed at expanding insurance enrollment among the uninsured population, including the Affordable Care Act, may consider the ED's potential as an effective enrollment site.

Availability of insurance linkage programs in U.S. Emergency departments.

INTRODUCTION: As millions of uninsured citizens who use emergency department (ED) services are now eligible for health insurance under the Affordable Care Act, the ED is ideally situated to facilitate linkage to insurance. Forty percent of U.S. EDs report having an insurance linkage program. This is the first national study to examine the characteristics of EDs that offer or do not offer these programs. METHODS: This was a secondary analysis of data from the National Survey for Preventive Health Services in U.S. EDs conducted in 2008-09. We compared EDs with and without insurance programs across demographic and operational factors using univariate analysis. We then tested our hypotheses using multivariable logistic regression. We also further examined program capacity and priority among the sub-group of EDs with no insurance linkage program. RESULTS: After adjustment, ED-insurance linkage programs were more likely to be located in the West (RR= 2.06, 95% CI = 1.33 - 2.72). The proportion of uninsured patients in an ED, teaching hospital status, and public ownership status were not associated with insurance linkage availability. EDs with linkage programs also offer more preventive services (RR = 1.87, 95% CI = 1.37-2.35) and have greater social worker availability (RR = 1.71, 95% CI = 1.12-2.33) than those who do not. Four of five EDs with a patient mix of ≥25% uninsured and no insurance linkage program reported that they could not offer a program with existing staff and funding. CONCLUSION: Availability of insurance linkage programs in the ED is not associated with the proportion of uninsured patients served by an ED. Policy or hospital-based interventions to increase insurance linkage should first target the 27% of EDs with high rates of uninsured patients that lack adequate program capacity. Further research on barriers to implementation and cost effectiveness may help to facilitate increased adoption of insurance linkage programs.