Academic journal article Health and Social Work

Effects of Social Work Intervention on Nonemergent Pediatric Emergency Department Utilization

Academic journal article Health and Social Work

Effects of Social Work Intervention on Nonemergent Pediatric Emergency Department Utilization

Article excerpt

Clinicians, administrators, and payers agree that the most efficient and cost-effective use of hospital and financial resources is served when emergent care is reserved for people in medical crisis and is confined problems that cannot be managed in primary care settings. Nonemergent cases interfere with the operation of the emergency department (ED), and the cost of such care is excessive (Gadomski, Perkis, Horton, Cross, & Stanton, 1995; Glotzer, Sager, Socolar, & Weitzman, 1991; Hurley, Freund, & Taylor, 1989). Moreover, the ED is not an optimal setting for primary care, and visits to the ED may weaken relationships with primary care providers (Gadomski et al.; Glotzer et al.).

Other factors preclude treating children for nonemergent problems in an emergency setting. Each time a child is brought to the ED he or she will likely see a different physician, usually not a pediatrician (Foltin, 1995). The examining doctor typically does not have the child's medical record. The focus is on the immediate need, and the environment does not encourage asking for or providing anticipatory guidance and preventive education or following up on previous visits. There is no opportunity to develop ongoing relationships (Rosenzweig, 1993), and it may be more difficult to diagnose pediatric chronic illnesses or to detect cases of child abuse or neglect.

Services provided by social workers, such as service coordination, counseling, referral, and linkages with community resources, when available in emergency settings, are not typically used to promote primary care. No reports in the literature could be identified that discussed studies of social work intervention to reduce ED utilization of children with nonurgent care needs, but as early as 1976 a role for emergency room social workers was defined as helping patients find appropriate alternatives for care (Bergman, 1976). McCoy, Kipp, and Ahern (1992) reported that social work intervention reduced repeat utilization 28 percent among older adults with mental health or social health problems who relied on the ED instead of seeking mental health services. Keehn, Roglitz, and Bowden (1994) studied adult ED patients who received social work services and found that the greatest decline in ED recidivism occurred when social workers used proactive intervention strategies.

Although it has been suggested that managed care would resolve the issue of whether nonemergent cases would be treated in ED settings, research has not demonstrated that turning away nonemergent patients produces desired outcomes (Glotzer et al., 1991; Losek, Walsh-Kelly, & Alstadt, 1987; MacKoul, Feldman, Savageau, & Krumholz, 1995; Mayefsky, Shirraway, & Kelliker, 1991). Evaluations of programs with physician gatekeepers have produced varying results (Hurley, Gage, & Freund, 1991; MacKoul et al.). In one study gatekeeping combined with parent education and 24-hour access to a primary care physician reduced ED visits (Franco, Mitchell, & Buzon, 1997). But a brief educational intervention alone has not been shown to alter utilization habits (Chande & Kimes, 1999; Chande, Wyss, & Exum, 1996). Gadomski and colleagues (1995) concluded that diverting Medicaid children classified as nonemergent in an emergency room to their primary providers was a safe short-term practice. However, denial of an emergency visit had no impact on subsequent ED utilization (denied patients subsequently used the ED as frequently as patients who had not been denied) and was associated with a higher rate of hospitalization. This type of gatekeeping did not change the health care-seeking behavior of these patients and may have resulted in higher costs. The authors argued that gatekeeping is usually understood as a denial of nonemergent visits but has been framed as directing into primary care, emphasizing the benefits that accrue from continuity of care. This effect was not demonstrated by their study, in which only 40 percent of those denied care were seen by their primary care provider. …

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