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There is no day or night in the Emergency Department (ED). Under bright florescent lights, patients arrive at all hours and the fast-paced environment often leaves little time to reflect on how they got there in the first place.
Nicole Furey is looking to change that one patient at a time by bringing together the ED with community agencies to support patients after they leave the hospital.
"Emergency, General Internal Medicine staff, and various agencies have come together at Toronto General Hospital (TGH) to help us facilitate patient discharges to their homes or residences, if safe to do so," says Scott McIntaggart, executive lead, TGH.
"This has had a huge impact because it has allowed us to accommodate about 900 more patients in one year because we were able to discharge patients directly from emergency with appropriate community services."
An example of this impact is a case where the ED came together with a community agency to focus their efforts on one patient — someone who had visited the ED at TGH more than 150 times in a year despite being medically stable.
Facilitating the meeting was Nicole, evening social worker in the ED, who brought everyone together because the patient's needs were beyond healthcare and included complex social issues such as addiction and homelessness.
"If we're not addressing those social determinants of health, there's a certain population that we're just letting fall through the cracks," says Nicole. "We're going to keep seeing those patients and we're not going to be improving their quality of life so I think that's a big part of the social work role in the Emergency Department."
The work of social workers in the ED is helping have better outcomes for the patient—and the hospital.
In this role, much like the rest of the ED, Nicole never knows what to expect when she walks into work. As one of two social workers here, she helps patients find and access support in their communities, rather than coming into the hospital unnecessarily.
Social factors such as income, food security, addiction, and access to housing mean that marginalized and isolated patients often rely on the ED for non-medical support. Her goal is to make sure that they don't need to come back.
Taking the time to listen
Originally from Newfoundland, Nicole completed her master's degree in social work with a focus on health and mental health in Toronto. She knew that she wanted to work in a hospital based on previous personal health experiences that got her thinking about the potential impacts of social work in healthcare.
It didn't occur to Nicole that working in the ER was a possibility. A new position for her and the hospital, the role was created as the result of a six-month pilot study which looked at the benefits of a social worker for both patients and the hospital.
Much of her time is spent simply listening to patients and their needs. Working in collaboration with other social workers and community agencies, she matches patients with the right resources and referrals to help them manage independently.
"It's very busy here and it's hard to have long, meaningful, in-depth conversations with patients sometimes," says Nicole. "But I often have the luxury of doing that when other professions just don't."
More efficient use of hospital resources
For patients who are medically stable but have social concerns, Nicole emphasizes that the hospital isn't the right place to be. For example, patients may be exposed to communicable diseases and elderly patients are at risk for delirium under the constant light. These factors make helping patients find community health and social support the priority.
"Being hungry, being addicted, being cold...those things don't go away at 5 p.m.," says Nicole. "That's what justifies the need to have social work in the [Emergency Department]."
Having a social worker in the ED can also alleviate the workload for the rest of the team, including physicians and nurses. This frees up the time of medical staff which allows more patients to be treated, preventing increased wait times and potential safety issues. It also allows for more efficient use of hospital resources such as inpatient beds.
In the evenings, Nicole is the only social worker in the ED at TGH. For her, the most difficult part of the job is seeing a lot of patients who need support, whether for housing or addiction, and not being able to help everyone because there just aren't enough community resources available.
Another challenge is finding support for herself – this is when she relies on the rest of the team and other ED social workers across the city.
"Some days it's really hard," says Nicole. "It's very fast-paced and sometimes you don't get a chance to mentally process what you are doing and what you've been through."
Making a difference through collaboration
What keeps her motivated is finding ways to make even the smallest difference in a patient's life. As the result of the meeting about the patient who visited the ED at TGH more than 150 times, the team was able to find appropriate housing for the patient. If they hadn't, Nicole believes that the patient wouldn't have survived another season on the streets.
Fortunately, the patient hasn't been back to the hospital since.
While social work is an important component of the ED, Nicole maintains that it's the collaboration between the medical team and community agencies that work to make a lasting mark.
"A lot of it would be for nothing if the follow-up wasn't there when people go home—that's what really helps people stay in the community and not in the emergency department," says Nicole.