By Clarissa Donnelly-DeRoven
On a sunny day last September, 20-year-old Haripriya Dukkipati walked into Duke’s emergency room for her first volunteer shift. The day started off slow. She and another student volunteer approached some patients and introduced themselves.
Then they asked whether the patients would like to be screened for any “unmet social needs,” namely: did the patients have enough to eat? Somewhere safe to sleep? Could they pay their bills? And if not, did they want help solving those problems?
After the first few people they approached said no, they noticed one woman in a wheelchair, periodically glancing over at them. She rolled herself over and asked what they were doing. They explained the project and asked if she needed help.
“And she just immediately goes, ‘Yeah, I do, because my husband left me to join ISIS,’” Dukkipati remembered. She and the other volunteer were shocked but they had a job to do.
The woman told the students she needed help affording food and paying her rent. They took her history, and enrolled her in NCCARE360, a new platform connecting individuals with different social service agencies that can help address their needs.
Since 2018, undergraduate students at Duke have volunteered with the program, called Help Desk. The first few cohorts of students spent their volunteer hours at the Lincoln Community Health Center, an organization that serves low-income people on the other side of Durham, away from the Duke campus. There, they mostly spent their time calling people who’d already been referred to social service agencies by caseworkers to make sure the patients had been able to access what they needed.
By 2021, the program had expanded into the ER at Duke with the help of emergency medicine physician John Purakal.
“The idea behind it,” he said, “was that we are going to address [patients’] unmet social needs in parallel with their medical care.”
They dubbed the program ParallelED.
Making the most out of long waits
The students volunteering in the emergency department go through about two months of training before they can sign up for a shift. They learn about how social factors — such as hunger and housing instability — impact health, what social service agencies in their region help people with these issues, how to navigate these resources, and how to use the NCCARE360 platform. They learn that they’re supposed to refer people with significant needs, such as those experiencing domestic violence, to the hospital social worker.
They also practice interviewing techniques, shadow an experienced volunteer, and receive feedback on their progress. Then, they call patients a few days after to check in.
“Every week we have case reviews where volunteers come together and talk about what happened in their week,” said Gene Moon, a senior at Duke and the program’s volunteer coordinator. “It’s a continual learning process.”
During their interviews with patients, students follow a form used by agencies nationwide to screen people for social needs. But it’s complicated to integrate it into traditional medical care.
Purakal said that there’s no clear recommendation on when or how to do this, but getting to patients in an ER waiting room seems like a good bet.
“What happens is you’ll get a patient who comes in for abdominal pain,” Purakal said. “You address their abdominal pain and they’re feeling better and you’re ready to discharge them and the nurse or doctor is coming in with discharge paperwork, and then they say, ‘Oh, by the way, I don’t have anywhere to go tonight.’”
Dealing with these issues proactively, at the start of somebody’s visit, is beneficial for patients, doctors and social workers, Purakal said. Without a formalized screening process in place, these needs come up, but they invariably get mentioned at the end of a visit.
“The emergency department is extremely busy. We’re not going to go through every unmet potential social need if it has nothing to do with the medical condition you’re coming in with,” he said.
“Mentally, everybody involved in this scenario was about to close the book on this. And now you, as a physician, have to be like, ‘Okay, so now I can’t discharge you and now I have to contact the social worker or case manager who has probably four or five people ahead of you.’”
It’s stressful for everyone involved, especially the patient.
“[They] get this kind of eye roll, like ‘Why did you bring that up?’” Purakal said. “In some ways, it makes them not want to even stay to address it.”
Unrelated to medical care
Emergency departments — especially in the COVID-19 era — have been experiencing exceptionally long wait times. While this isn’t great for patients, it does present an opportunity for ParallelED, and other experiments like it. It offers a clear space where they might intervene to help people get their non-medical needs met — non-medical needs which very often have a tremendous impact on their health.
Studies estimate that between 80 and 90 percent of the things that impact a person’s well-being are unrelated to medical care.
“We see the folks [in the ER] who don’t have insurance, who don’t have access to care, who are more likely to have housing instability, are more likely to have food insecurity, who are more likely to have language barriers to care,” Purakal said. “The emergency department is a whole different beast unto itself.”
A 2017 study in the journal Health Affairs found that uninsured patients actually go to the emergency room at about the same rate as people with insurance, but they go see other doctors less, so they are often sicker when they arrive at the ER.
“It’s one thing to be stationed in a clinic in a waiting room in a very controlled environment,” Purakal said, “It’s another thing when our waiting room is like 50, 60 people deep every day — really sick patients, sometimes psychiatric patients.
“These students are sitting right out there, in the waiting room, with them.”
At the start of the project, some people — including volunteers — had concerns about how willing patients would be to speak about these issues in a public place such as an emergency room, and with undergraduates. But so far, it doesn’t seem like a barrier.
“Once [patients] feel like there’s someone there who’s willing to listen to them and who’s willing to reach out and provide some kind of assistance,” Dukkipati said, “they’re so much more open, and they’re so much more willing to speak freely, and tell us not just about the questions that we asked them but just in general about their life and about other struggles that they’re facing.”
Is it working?
Graduate students have been collecting data on the intervention and analyzing it. Purakal said some of the students will attend the Society for Academic Emergency Medicine’s conference in May to present their findings.
Their tentative data show that the program has screened 172 patients. Eighty percent of those people had at least one unmet need, and 67 percent had more than one. The majority of the patients were women, Black and from Durham County.
Eighty-four percent of the referrals the students made were for food, housing, transportation or utilities.
The student volunteers, quasi-social workers, really, say it can be nerve wracking to approach strangers and ask them about some of the most intimate details of their lives. But helping people get the resources they need is worth the butterflies and sweaty palms.
“I’m just surprised by how many people fall through the cracks,” Moon said. “And the fact that we’re screening them as volunteers — it’s crazy to me because if we weren’t there then who knows where they would get their housing or their food?”
Moon and many of the other Duke volunteers want to become doctors. They think this experience, and the knowledge it has instilled in them, will make them much better physicians and — hopefully — make healthier patients.
read more about how social factors impact health
“This experience has taught me that health isn’t just biology or physiology,” Dukkipati said. “There’s so many social factors and cultural things that go into our health and affect our health care and our health outcomes.”
Dukkipati took the MCAT last year, the medical school entrance exam, and she said while there is a section on the exam about social psychology, there isn’t much about how social factors impact a person’s health. She’s double majoring in biology and sociology — the second one because of her experience with ParallelED.
“But if someone was just doing a pure pre-med track and majoring in a natural science,” she said, “I don’t think they would be getting too much exposure to these kinds of concepts.”