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Embedding palliative care-trained social workers in hospital emergency departments can help health care providers effectively serve some of the most vulnerable patients.
Populations who most need palliative care are often chronically ill seniors with complex health conditions. Between 2014 and 2017, these patients accounted for more than 20% of all emergency department (ED) visits in the United States, according to the U.S. Centers for Disease Control and Prevention (CDC).
However, the needs of these patients become even more complex when they are uninsured, unhoused, disconnected from family or otherwise lacking a support system according to Terry Altilio, a palliative care educator and retired social work coordinator formerly with the Division of Palliative Care at New York City’s Mt. Sinai Beth Israel. She is also editor of the Oxford Textbook of Palliative Social Work, second edition.
“At Beth Israel, we were meeting people who were either in fractured family relationships, lost a family, and came to see that people who get their primary care in the ED [are] either unhoused folks or disenfranchised folks, that while we may see them sometimes as burdensome and on our best best days treat them with kindness and competence,” Altilio told Palliative Care News. “Many of these folks have no idea what the decision making process will be around them if they become seriously ill and find themselves in our institutions with no family and no surrogate to advocate for them.”
By having palliative care social workers in the ED, these patients can have goals-of-care conversations, get a better understanding of their illnesses, seek help reconnecting with family and potentially find alternative routes to care, including hospice when appropriate, Altilio said.
Research backs these claims. Having palliative care clinicians on deck in the ED can ease burden on the department’s staff and help ensure that patients receive goal-concordant care, according to a recent study published in the Journal of Palliative Medicine. The program described in the research also generated a 6.7x return on investment, the study indicated.
These types of services are often unavailable in the frenetic environment of hospital emergency rooms. ED staff generally lack the time and training to provide them, and the systems in which they work are not designed to address long-term considerations.
Palliative social workers can help patients and their clinical colleagues start thinking about the bigger picture, according to Maya Genovesi, associate director of social work services at the Mount Sinai Hospital in New York City.
“These patients will eventually die, or they will eventually get more ill, which is actually not how emergency medicine providers think. They think I’m taking care of a patient in this discreet encounter,” Genovesi told Palliative Care News. “Social work can provide a larger picture about almost seeing into the future about what this patient is going to need, not just now, but in the long view of care.”
These social worker visits in the ED can also help patients avoid unnecessary hospitalizations and transition to hospice when they become eligible, Altilio said.
Again, research agrees. The Journal of Palliative Medicine study indicated that among the patients who received the consults, 49% had a changed code status; 11% were admitted to a lower level of care, and 11% avoided hospitalization. In addition, 17% received hospice referrals, and 21% were referred to a palliative care outpatient clinic.
The program also led to significant reductions in hospital lengths of stay, the study indicated, and staff perceptions of the initiative were very positive. The consults yielded $5,974 in median direct cost savings for index hospitalization, per patient.
“We have a mission here,” Altilio said. “The mission is to understand this person over time so we can put them in a position where they’re at least making decisions about dignity at the end of their lives. It helps them feel less helpless.”