Social Determinants

Language

Many ED patients do not speak English as a first language. Title VI of the Civil Rights Law requires all recipients of federal funding to provide interpretation for patients with limited English proficiency. With time pressure in the emergency department and lack of proper training, providers do not always use a certified interpreter and instead use their limited knowledge of a second language or a patient family member. Failure to use a certified interpreter leads to poorer health outcomes and persistent health disparities. Given this, emergency clinicians should use certified interpreters for patients with limited English proficiency.

Health Literacy

Even patients who speak English as a first language may have limited health literacy, which is defined as limited capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Those who have low health literacy may have trouble with tasks including reading appointment slips, understanding medication labels, and comprehending information from their providers, all of which are associated with poorer adherence to care plans and poorer health outcomes. To address this, ED providers can use techniques such as “teach back” by providers and engaging with family members and friends to support patients.

Insurance and Access to Care

Uninsured and underinsured patients are often unable to access care prior to an ED visit. This leads to delayed presentations of serious health conditions, poor health outcomes, and higher mortality. For those who have poor access to care, two of the main drivers are the lack of ability to afford care and low health literacy regarding how to utilize care once coverage is obtained.

For emergency clinicians, insurance and access to care are crucial to ensure proper follow up for patients. Rapid follow up reduces both return ED visits and avoidable hospital admissions. Thus, making sure patients have a practical and accessible follow-up plan is key. For those patients who have trouble navigating the system, case management can reduce ED recidivism.

Employment, Income, and Financial Strain

The United States (US) has an extremely high rate of income inequality that has continued to grow in recent years. ^, As income inequality has grown, so have health care disparities: lower-income Americans have higher rates of chronic disease, anxiety, and depression, as well as lower life expectancy. ^, Low income, financial strain, and resulting poverty lead to increased stress, poor access to healthy foods, unsafe housing, and challenges with other SDOH.

Medical debt is related to income, employment, and financial security and is estimated to contribute to 67.5% of all bankruptcies, even after passage of the Affordable Care Act. Hospitalization itself leads to decreased employment and income with a rise in out-of-pocket spending on medical care. This highlights the importance of ensuring patients are connected to health care coverage and other programs to minimize the impact that an ED visit and/or hospitalization has on their lives.

Food Insecurity

Food insecurity, defined as a condition in which individuals do not have access to nutritionally adequate and safe food because of limited financial or other resources, is a leading health issue in the United States. Lack of access to healthy foods leads to increased rates of low birth weight, hypertension, diabetes, and mental health disorders, particularly depression. Not surprisingly, this is associated with increased emergency department visits and acute care utilization and therefore increased costs within the health care system. Food insecurity led to an estimated $53 billion dollars of excess health care spending in the United States in 2016.

Food insecurity leads to poor health by forcing individuals to choose between eating and medications, medical care, housing, education, utilities, and transportation. Furthermore, food insecurity makes it difficult for individuals to follow a healthy diet and reduces the cognitive bandwidth available to manage chronic illnesses.

Poverty, lack of education, and unemployment lead to individuals and households not having enough to eat and substituting cheaper, less nutritious items for healthy foods or choosing not to eat to meet other basic needs. Low-income individuals often live in areas that have been historically underdeveloped with poor public transit and lack access to healthy foods. These areas, known as food deserts, lead to poor outcomes for those with chronic disease, including cardiovascular disease and diabetes.

Homelessness and Housing

Lack of access to safe, habitable housing is an important social determinant of health for many patients. These individuals have worse health outcomes and mortality compared with those who are housed. Unhoused individuals may be unable to properly store certain medications, which can affect their efficacy (e.g., refrigeration of insulin or other antidiabetic agents may not be possible). Additionally, patients with housing insecurity may take irregularly or avoid taking certain medications based on expected side effects and potential legal implications. An example includes the use of diuretics, which cause increased need for urination; due to lack of access to bathroom, patients may be unable to reliably relieve themselves or be charged with indecent exposure or public urination. Housing First programs that provide housing and supportive case management decrease the use of nonroutine health care services, including ED visits, while improving self-perceived health. ^, However, compared to other federal, state, and local means-tested programs such as Medicaid and SNAP, housing programs have a limited supply and long waitlists.

For those with housing, utility payments can be challenging. Utility assistance programs are available for low-income patients and have been shown to improve health. ^,

Transportation

Lack of access to transportation leads to missed appointments, poor adherence to medications, and delayed access to care, resulting in increased costs and poorer health outcomes. Lack of transportation also impacts access to services, healthy foods, jobs, and other social determinants of health. Barriers to transportation include poor infrastructure, costs, lack of access to vehicles, distance and time burden, and policy-related issues.

Elders, veterans, children, women, minorities, and those with lower incomes and chronic conditions face more transportation barriers. Rural settings are especially challenging, given the great distances and lack of public transportation. Providing transportation improves adherence to care, thereby decreasing costs and improving outcomes.

Immigration Status

The immigration experience has profound effects on individuals and their health. Immigration status is linked to ability to work and access public benefits, including health care. The lack of proper immigrant status causes stress and poorer health. Immigration law and policy are complicated and continuously changing. Important interventions that can be initiated in the ED include identifying vulnerable patients and educating them about potential opportunities to adjust their immigration status through mechanisms such as the T-Visa, U-Visa, and Violence Against Women Act (VAWA), as well as providing education and dispelling fear regarding accessing medical and social services.

Education

Youth behavioral issues in school can be related to mental health or developmental delay, resulting in the youth being brought to the ED. Parents or guardians may express concerns regarding the issues of truancy, suspension, expulsion, and reasonable accommodation, challenges that appropriate social services can help them address. For adults, educational needs are more subtle and tied to employment opportunities and income. Lower educational attainment is correlated with lower health literacy and poor health outcomes. More years of education are directly linked to a lower risk of mortality, a lower risk of obesity, and a lower risk of smoking.

Legal Concerns

Health-harming legal needs is a term used to describe the legal avenues that exist to address many SDOH. For example, if an individual has mold, pests, or other housing issues that a landlord refuses to address, or an individual is improperly denied Medicaid coverage for durable medical equipment, a lawyer can help advocate and enforce housing and Medicaid regulations, respectively. Addressing SDOH through the law diminishes stress, decreases ED visits, and improves adherence to care and health outcomes.

Justice Involvement

The United States has the largest population of incarcerated individuals in the world. Individuals in custody or otherwise justice-involved are often seen in the ED. Many of these individuals experience comorbid psychiatric and substance use disorders, chronic health conditions, or homelessness, making these populations extremely vulnerable. Furthermore, individuals in custody lose their rights and privacy. Being justice-involved is associated with higher mortality, morbidity, and poorer health outcomes.