Rethinking “socially admitted” patients

Labelling vulnerable patients in hospital as “socially admitted” may prevent treatment of medical issues, according to new research in CMAJ (Canadian Medical Association Journal) https://www.cmaj.ca/lookup/doi/10.1503/cmaj.231430.

Emergency departments are the last resort for some socially vulnerable people who may not have an acute or new medical issue. They may be seeking care because of a breakdown of supports or the inability of the patient, or their family, to cope with living at home. These people are known colloquially as “social admissions,” and other labels such as “orphan patient,” “failure to cope,” and others have been applied.

“The ‘social admission’ phenomenon is an under-researched area in health care,” writes Dr. Jasmine Mah, an internal medicine resident with an interest in geriatrics at Dalhousie University, Halifax, Nova Scotia, with coauthors. “These patients, often categorized by health care providers as not being acutely ill, experience in-hospital death rates as high as 22.2%–34.9%. Explanations may include under-triaging in the emergency department owing to poor recognition of atypical clinical presentations and delays in timely assessments.”

 Furthermore, patients may be misdiagnosed or develop acute illness in hospital.

To better understand this category of patients, researchers undertook a qualitative study to explore the views of health care providers on patients admitted as “social admissions” in Nova Scotia. They identified 9 themes, including stigma, prejudices such as ageism, wait-lists, and other factors that contributed to views about caring for these patients.

“Our findings highlight the potential adverse effects on care when patients are labelled as ‘socially admitted’ (or as ‘orphan patients’ in the study hospital), such as incorrect assumptions about medical needs and cognitive abilities, which impedes opportunities to look for treatable medical issues,” write the authors.

Labelling patients negatively affects their health and can have a negative impact on health care providers. Many providers were conflicted in how to deliver care and felt that these patients deserved care, but almost always from someone else.

“This pattern of downgrading care can lead to situations in which ‘socially admitted’ patients are looked after by team members who possess minimal experience recognizing evolving medical presentations or lack the authority to advocate strongly for clinical reassessments when needed. The implication that the care of ‘social admissions’ should be delegated to others reflects an implicit attitude of hierarchy and detachment from the needs associated with this patient population,” they write.

The authors urge a reform of current structures and hierarchies to improve care for these vulnerable people. 

In a related editorialhttps://www.cmaj.ca/lookup/doi/10.1503/cmaj.240577, CMAJ deputy editor and emergency medicine physician Dr. Catherine Varner, with coauthors Dr. Andrew Boozary, a primary care physician and executive director of the UHN Gattuso Centre for Social Medicine, Toronto, and CMAJ editor Dr. Andreas Laupacis, suggests we need to reframe this issue as a policy failure to help solve the problem. In Ontario, for example, alternate level of care policies that punish hospitals and patients for occupying beds despite no longer needing acute care do not solve the problem.

“Punitive policies like these cause distress to patients, families, and providers and have not restored hospital occupancy to manageable levels,” write Dr. Varner and coauthors. “These policies are also at odds with most health care workers’ deep commitment in wanting to do better for patients who are otherwise let down by the broader health and social care systems.”

Embedding collaborative, supportive programs such as multidisciplinary geriatric teams in emergency departments to manage frail older patients and health teams to support vulnerable people are examples of solutions.

“To restore human dignity in health care — to properly address the barriers experienced by patients and the moral distress of health providers — structural factors causing health disparities must be confronted as policy failures, not personal ones,” they conclude.