Date of Publication


Project Team

Laura Lewis and Allison Bovee


Background: Frequent emergency department use is defined as four or more visits a year. Individuals who frequent the emergency department often have social and health inequities, chronic illness, and live in rural settings. Healthcare complaints associated with frequent emergency department use can typically be managed in a primary care setting. Decreased emergency department use is a suspected outcome of addressing unmet social needs.

Purpose: Outcome measures include: 1) number of individuals seen in the emergency department on a weekly basis; 2) how individuals were called by the site RN and then subsequently screened for unmet social needs; 3) identified unmet social needs; 4) number of follow-up visits scheduled with the patient’s primary care provider; 5) nurses’ perception of tools.

Methods: Developed and implemented a conversation guide and social determinants of health screening decision tree to be used by nurses when contacted patients of a primary care clinic in the Northeastern United States recently seen in the emergency department. Data sets were analyzed using a run chart to compare pre and post intervention values.

Results: Compared to benchmarking data, there was an initial decrease in percentage of follow-up phone calls in the first PDSA cycle, followed by an increase in the second PDSA cycle. No individuals screened positive for unmet social needs. Staff found the script useful and allowed for a more direct conversation.

Discussion: Recommendations for future practice include increased use of social determinants of health screening during routine office visits and continued inclusion of conversation script for nursing directed phone calls.

Document Type


Included in

Nursing Commons