Taylor Phillips & Linda Wu
THE PATIENT DISCHARGE INITIATIVE
The Patient Discharge Initiative is a health advocacy organization composed of undergraduate students from Rice University and the University of Houston that aims to understand and address health disparities faced by underserved patients seen at Ben Taub Hospital.
health disparities, social determinants of health, health advocacy, Houston, Rice University, University of Houston
Due to the highly price-driven healthcare market, America’s emergency departments (EDs) often serve as the primary provider of care for several at-risk populations, such as those who are uninsured, underinsured, low-income, racial and ethnic minorities, and immigrants. Around one-third of EDs in the United States are classified as safety-net burden providers and see a disproportionate number of non-emergent, primary care-related cases (Burt & Arispe, 2004). Most of the factors that cause overuse of EDs in safety-net burdened hospitals by at-risk populations can be attributed to income, physical environment, and overall access to services and food that lead to health inequities (NCHHSTP, CDC, 2021).
Houston, Texas, is particularly illustrative of the problems created by these inequities. Despite being one of the most diverse cities in the United States, healthcare systems in Houston still present immediate barriers for Black and Latinx patients. According to a 2019 survey, almost half a million residents lived in food deserts, which are defined as regions of the country that often feature large proportions of households with low incomes, inadequate access to transportation, and a limited number of food retailers providing fresh produce and healthy groceries for affordable prices (USDA, 2012). As a result of lacking access to healthy foods, three-quarters of Black and Hispanic residents were overweight or obese (Harris County Public Health, 2021). Additionally, one-third of Hispanic adults reported being unable to seek preventive, routine, or diagnostic medical services because they could not afford them or were uninsured. This lack of regular medical care often leads to patients being forced to depend on EDs for care, placing significant strain on the city’s healthcare system (Nguyen et al., 2014).
On average, over one million ED visits are made each year in Harris County–Texas’ largest and fourth-largest county in the United States. Policies such as the Emergency Medical Treatment & Labor Act (EMTALA), which is a 1986 federal statute mandating immediate care and treatment for anyone who enters an ED regardless of insurance status and ability to pay, and the establishment of “safety net hospitals,” which are medical institutions that have the legal obligation to provide healthcare without regard to insurance and ability to pay, as led to ED overuse (Kelen et al., 2021 & Weiss et al., 2004). For instance, Ben Taub Hospital and Lyndon B. Johnson Hospital, the only two EDs in the Harris Health System (out of 36 EDs total in the city), have over 100,000 yearly cases, averaging nearly four hundred visits per day (Harris Health System Annual Report, 2021). Over 40% of these visits were related to primary care, which included non-urgent and preventable conditions, such as flu, lower back pain, and upper respiratory illnesses. Over two-thirds of these visits were made by patients who were Black or Hispanic.
Treatment in the emergency department does not guarantee longer-term health maintenance given environmental, social, and economic conditions. (UTHealth SPH, 2012). 45% of patients who utilize ED services for primary-care-related visits credit barriers to access to primary care for their ED visits. However, while EDs can only provide acute care, many patients experience poor coordination of care post-discharge, such as getting prescription refills, lack of follow-up appointments, specialty referrals, and other services that a primary care provider could only provide. Ultimately, ED visits become a bandaid for emergency issues as the health concerns and reasons behind the initial ED visit are likely to occur again, thus feeding a vicious cycle.
In 2011, Baylor College of Medicine students Dennis Shung ‘14 and John Lin ‘14 established the Patient Discharge Initiative (PDI) to improve post-discharge quality of life for Ben Taub patients in response to ED overuse and to address the barriers to primary care. PDI obtained its initial funding from the prestigious national Albert Schweitzer Fellowship, which supports service projects to meet the health needs of underserved populations. Today, the Patient Discharge Initiative has over 90 student members from Rice University and the University of Houston, with hospital physicians advising the initiative.
PDI volunteers work with patients to improve their health outcomes in several ways following their ED visits. They work directly with patients in EDs to ensure that they understand their diagnosis, treatment, and medications. Then PDI connects them with relevant community resources to utilize post-discharge to facilitate access to longer-term health solutions and decrease reliance on EDs. PDI uses a comprehensive screening process to help patients identify their long-term needs and address the social determinants of health that may lead to specific health disparities among vulnerable populations. The screening process, developed by the Centers for Medicare & Medicaid Services (CMS), assesses a patient’s housing status, access to transportation, food insecurity, educational or employment needs, insurance, and overall ability to pay for medical costs. From this screening process, PDI volunteers can connect patients to Houston-area resources, such as English-as-a-Second-Language classes or language interpretation services, legal aid, housing assistance, access to food, and other community resources to target patient needs.
During the COVID-19 pandemic, PDI could not continue their usual volunteering work at Ben Taub’s emergency department. The organization instead strengthened the education of its volunteers through internal committee projects and assisting the Mayor’s Office of Education with public health curricula. Other committee projects included a panel of healthcare leaders who shared their experiences addressing social determinants of health, writing thank you notes to local front-line healthcare workers, hosting a health policy hack-a-thon for college students in Houston, and partnering with their organizations’ emergency physician mentors to research and learn more about factors preventing patients from securing insurance. PDI is also working to bring its services to a virtual text messaging service that further connects patients with community resources beyond Ben Taub Hospital.
(From PDI Manuscript) In a nine-month survey of 494 patient encounters, PDI found that over half of patients reported successfully utilizing community resources received from the ED intervention and were almost 50% less likely to return to the ED 90 days after discharge than those without PDI’s intervention and higher attendance rates for 90-day follow-up appointments. Since 2019, PDI has expanded its initiative to community partnerships within Harris County by establishing a chapter at the University of Houston. PDI has further fostered a collaboration with the Harris Health Population Health Department to strategically expand their reach and integrate their work into the health system to directly improve the care of all patients seen at Harris Health. Fostering relationships throughout the community has proven to be a decisive factor in PDI’s ability to optimize collective efforts to create healthier and more equitable communities.
Sahana Prabhu and Daniel Wang, interview by Taylor Phillips, March 10, 2021, interview, transcript, and recording, Medicine, Race, and Democracy Lab Collection
Harris County Medical Society. “Social Determinants of Health,” February, 21 2021, https://www.hcms.org/tmaimis/HARRIS/Practice_Resources/Tools_and_Resources/Social_Determinants_of_Health.aspx?WebsiteKey=0a784a46-1152-4b41-8e5d-3545a059ff7f
University of Texas Health Science Center at Houston School of Public Health (UT Health SPH). “Houston Hospitals Emergency Department Use Study,” June 2012, https://sph.uth.edu/content/uploads/2013/06/Final2011ER.pdf