The Emergency Room: A Window into America’s Social Fractures

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The sterile glow of the emergency department (ED) can feel like its own world away from the messy realities of American life. But spend enough time in one, and you’ll quickly realize it’s a window, not a wall. It’s a window into our deepest societal cracks– homelessness, hunger, mental health crises, the struggles of aging, to only name a few.

As an emergency department social worker, I’ve witnessed firsthand the devastating impact of social issues on patients: homelessness, food insecurity, inadequate mental health care, legal challenges, and financial hardship, among others.

Yet, it’s not only about a lack or deficit in social needs; they’re symptoms of a broken system that has failed to provide adequate services. This is further exacerbated by systemic racism and the criminalization of poverty.

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It’s well known that malnutrition weakens the immune system, making individuals more susceptible to chronic diseases. This disproportionately affects low-income communities and communities of color, further widening existing health inequities. According to the U.S. Department of Agriculture, in 2021, 10.2% of U.S. households experienced food insecurity, meaning they lacked consistent access to adequate food. I’ve seen all of it, firsthand. Patients who request turkey sandwiches and water minutes after arriving.

How can we expect individuals with chronic diseases to afford nutritious food while also navigating the challenges of housing, mental health care, and other essential social services, especially when these services are often underfunded and inaccessible? Social services are a part of living. Essential for society, but notoriously underfunded.

Consequently, patients with chronic conditions like diabetes and congestive heart failure frequently return to the emergency department due to inadequate access to nutritious food, hindering their ability to manage their health.

In the ED, we see the human cost of that brokenness. People arrive with hypothermia, untreated infections, their bodies ravaged by the harsh realities of life on the streets. The ED becomes a temporary haven, providing a warm bed, meals, Wi-Fi, appropriate medical care, and a brief respite from their challenging circumstances. For some, the ED offers more than just medical treatment; it provides a sense of community and a temporary escape from the harsh realities of their daily lives. It’s always open and doesn’t turn anyone away. Yet it’s a band-aid, not a cure.

This offers only a temporary respite from their chronic health challenges–and consequently their social challenges. For example, if someone has depression with no family or friends, going to the emergency department will provide them with human interaction and a secure environment to prevent harm.

This is evident in the “frequent flyers” we see. That is, people who come to the emergency department ten or more times in a single year.

The data paints a similar picture. The Joint Commission–with its focus on social determinants of health–recognizes that factors like housing, food security, and transportation deeply impact our well-being.

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And then there’s the aging population. We see families struggling to care for elderly loved ones, overwhelmed and exhausted. The lack of affordable home care forces them into crisis mode, often resorting to the ED when they are unsafe in their own home. It’s a reflection of a society that hasn’t adequately prepared for the needs of its aging population.

Additionally, research demonstrates that social factors such as the lack of safe discharge plans due to incapacity or guardianship issues, significantly prolonged hospital stays. These challenges include finding suitable housing for elderly patients, connecting individuals with addiction treatment programs, and ensuring access to stable housing.

In many situations, families seek emergency medical assistance when their loved ones are unsafe at home, relying on the rapid response of first responders. For example, in Michigan, Adult Protective Services (APS) is mandated to initiate investigations within 24 hours, either by contacting individuals who know the person or the person themselves. A face-to-face assessment is then supposed to occur within 72 hours. However, during this waiting period, families often resort to calling 911. An ambulance typically arrives within an hour, and their loved one is immediately transported to the emergency department. Many families choose the immediate response of 911 and EMS transport to the hospital over waiting for APS intervention. This is often due to factors such as not knowing how to contact APS or a reluctance to wait for their intervention.

Some might say the ED isn’t the place to solve these problems. They’re right, it’s not. But the ED provides a unique vantage point. It’s a front-row seat to the human cost of our societal failures. By carefully analyzing the data, we can gain valuable insights into the most pressing needs within our communities. We can use this information to advocate for change–for more affordable housing, expanded mental health services, stronger social safety nets, and a system that truly supports the well-being of all its citizens.

Looking at specific hospitals, we can even gauge what services are needed the most, and use limited funding toward that service for maximum effectiveness. My rural hospital has an issue with transportation. We have one city bus that stops taking rides around 5pm, and a singular taxi which can be quite expensive even if city limits. There’s no uber, no subway, no car pool system. When someone arrives at the ED after taking EMS, many have no way to get home.

One community’s struggles may differ from others–such as large city vs rural. Again, hospitals have a front row to the specific societal challenges.

I urge all patients, residents, doctors, nurses, social workers, and hospital workers to write to their local representatives and politicians on what they are seeing in their individual communities. What are your patients’ top barriers, either to discharge or as identified during their stay? Don’t keep quiet. If you see a need, speak about the need for community services and advocate for further services.

All without breaking, HIPAA, of course.

The ED, with its open doors, reflects the best and worst of our society. It’s a mirror, showing us our strengths and our weaknesses. By looking honestly at that reflection, we can begin to build a healthier, more just society for all.

Allyssa-desiré is a licensed master social worker with a Masters in Social Work, a Bachelor of Science in Psychology, and a minor in criminal justice. All of her career ambitions are directed towards improving social justice.

Annotated list of references:

References:

Apa.org, 2021, www.apa.org/topics/racism-bias-discrimination/health-disparities-defined.

Fact sheet from the American Psychological Association.

Assess Health-Related Social Needs | The Joint Commission, www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/assess-health-related-social-needs/. Accessed 1 Jan. 2025.

Joint Commission’s Website. This page specifically goes to the types of SDOH and why they are needed.

Coleman-Jensen, Alisha, et al. “Household Food Security in the United States in 2013.” SSRN Electronic Journal, vol. 309, no. 275, 2022, www.ers.usda.gov/webdocs/publications/45265/48787_err173.pdf?v=0, https://doi.org/10.2139/ssrn.2504067.

A report summary from the Economic Research Service published on the USDA page.

Corrigan, Maura, et al. The Michigan Model Vulnerable Adult Protocol a Model Protocol for Joint Investigations of Vulnerable Adult Abuse, Neglect and Exploitation.

This is listed on the Michigan Government Website and includes Adult Protective Services Protocols. It acts as a handbook and set of requirements.

Pham, J. C., Bayram, J. D., & Moss, D. K. (2017, July). Characteristics of frequent users of three hospital emergency departments | agency for Healthcare Research and Quality. Agency for Healthcare Research and Quality. https://www.ahrq.gov/patient-safety/settings/emergency-dept/frequent-use.html

Study on factors that contribute to frequent emergency department usage.

National Alliance on Mental Illness. “Mental Health by the Numbers.” NAMI, Apr. 2023, www.nami.org/about-mental-illness/mental-health-by-the-numbers/

Link goes to “fast facts” about mental health and illness.

Riley, Wayne J. “Health Disparities: Gaps in Access, Quality and Affordability of Medical Care.” Transactions of the American Clinical and Climatological Association, vol. 123, 2024, p. 167, pmc.ncbi.nlm.nih.gov/articles/PMC3540621/.

Article outlining consequences of health disparities.

Stanley, Zosia, and Lisa Thatcher. “Allow Patients Waiting in Hospitals During Guardianship Processes to Transition to Appropriate Long-Term Care.” Washington State Hospital Association 2023 Policy Brief, 2023.

Policy brief from Washington State Hospital on the need to keep patients in the hospital during guardianship processes due to increase of guardianship demands.