Emergency departments treat frostbite, gunshot wounds, and overdoses. But what about homelessness, youth violence, and substance-use disorder?

Here and there across the nation, emergency departments are evolving to address the upstream causes of the acute events that bring people through their doors. And in the process, they hope to reduce utilization, shorten wait times for all patients, and curb the cost of care.

A range of initiatives focus on giving clinicians and staff tools to address the most urgent social challenges – because patients most affected will invariably turn up in the ED.

Here's a snapshot of current innovations designed to fix lives as well as wounds:

Rescuing victims of human trafficking

In one study, nearly 88 percent of victims of sex trafficking reported having had contact with a healthcare provider – 63 percent in an emergency room – without the provider being aware of their circumstance. So Dignity Health developed the Human Trafficking Response program to help staff at its 400 care centers identify victims of human trafficking, whether from the sex trade, agriculture, or domestic work.

Holly Austin Gibbs, herself a victim of trafficking, directs the program. Because “not all victims are going to self-identify or get help," Gibbs says, Dignity developed protocols to help staff to recognize red flags of trafficking – from a controlling companion to physical neglect – and then alert community resources, including first responders, before the patient leaves the ED. In 2016 alone, staff at Dignity's EDs rescued at least 31 victims.

Behavioral emergencies

At St. Mary's Regional Medical Center, a 233-bed hospital in Lewiston, Maine, behavioral health patients were not fans of the hospital's emergency department. When surveyed, “They said 'we need a place to walk around and we don't want to be shut up in a little room,'" says Michael E. Kelley, M.D., medical director of psychiatry.

So the hospital created a new emergency department specifically for behavioral patients, and hired psychiatric RNs and a nurse practitioner as well as a behavioral technician, crisis workers, and security officers. Telemedicine ensures 24/7 access to a staff psychiatrist.

The remodeled physical space makes patients more comfortable. “Instead of little rooms, we created an area almost like a hotel lobby with couches and a recliner and room to move around and relax," says Kelley. “Patients can walk and burn some of that energy."

The more relaxed atmosphere allows staff to redirect patients to resources in the community, reports Jason Rosenberg, R.N., director of the hospital's emergency and behavioral services. That in turn has turned the tide of admitting behavioral patients – reducing from 60 to 30 percent those being admitted through the general ED.

When the ED is 'home'

At the University of Illinois Hospital in Chicago, 48 percent of the top 100 users of the ED are chronically homeless. The population using the ED for care, says Stephen Brown, MSW, LCSW, is “more prevalent than we ever imagined … with exorbitant cost and utilization." Some of these patients, says Brown, even list the ED as their home address.

As director of the hospital's Better Health Through Housing program, Brown works with community partners to find free temporary housing for homeless high utilizers, and connects them with primary care for their chronic conditions.

Under a pilot program now in its second year, 50 chronically homeless patients have been housed, with an estimated initial cost reduction of 21 percent – and the savings are expected to increase, says Brown. “If every hospital in Chicago committed to paying for supportive housing for 10 chronically homeless individuals, we could reduce the population by a third."

Keeping elders at home

When elderly patients are admitted from the ED, hospital-acquired delirium can set in. “They are stuck in the hospital, and then tend to leave in a more fragile state than when they came in," says Vaishal Toila, M.D., medical director of the ED at the University of San Diego Hospital. To create an ED experience that's more likely to allow frail elders to go home rather than being admitted, UC San Diego opened the Gary & Mary West Senior Emergency Department.

The new unit accommodates elderly patients with non-skid floors and larger signage, iPads to track their wait times, and a dedicated pharmacist. In a study of 70 patients seen in the new ED, those sent home to be cared for by visiting nurses avoided the risks of inpatient stays and “did extremely well," says Toila.

Breaking the cycle of youth violence

Gun violence is the cause of nearly 39 percent of deaths among young people in Minneapolis – and Hennepin County Medical Center, a Level 1 trauma center, treats many of the victims. One finding: 40 percent of victims returned to the ED with subsequent injuries. “Over time, we realized we were bandaging up patients and sending them back into the same dangerous environment without the tools or resources to make a change," says Ann Eilbracht, senior director of support services for Hennepin.

To do more, Hennepin created Next Step, an intervention program to connect victims with resources and paths out of retaliatory dynamics. Since its launch, just three of 140 participants have returned to the ED. The key to Next Step's success? Eighty-five percent of victims agree to participate in the program because the intervention specialists are also young, with life experiences in common, enabling them to build trusting relationships with victims.

Alternatives to opioids

In Paterson, New Jersey, St. Joseph's Health's Alternates to Opiates, offers alternative therapies – trigger-point injections, nitrous oxide, and ultrasound-guided nerve blocks – for targeted conditions. Cofounded by Mark Rosenberg, DO, chairman of the emergency department, and Alexis LaPietra, medical director of the emergency department pain management program, Alternates to Opiates helps ED staff avoid opioid prescribing whenever possible, reducing the risk of substance-use disorder among its patients.

Up to 75 percent of ED patients now achieve adequate pain relief without opioids, says Rosenberg. The outcome has been “phenomenal," he says, and the program is being expanded throughout the hospital.

As the front door to the healthcare system, EDs are expanding their scope of care in order to reduce utilization. Because emergencies don't start in the ED, or end there.

Joe Cantlupe is a frequent contributor to athenaInsight. Artwork by Tiffany Chan.