Social Work Navigation Program in Emergency Department to Address SDOH Needs


Social determinants of health (SDOH) have a major impact on people’s health, well-being and quality of life.¹ In May 2022, NorthShore-Edward Elmhurst Health, an integrated health system in Northern Illinois, recognized that patients were being bedded on the inpatient units from the emergency department who did not require the level of inpatient care. These patients were identified to have complex psychosocial or placement needs that current resources could not address nor coordinate in the emergency department. In response, an emergency department social work navigation program was developed to provide care coordination to patients with complex psychosocial needs in the emergency department. The goal of this program is to provide high quality care coordination, minimize unnecessary admissions, improve care transitions and enhance the patient experience by addressing the patient’s social determinants of health needs within our community we serve.

When patients entered the emergency department, they were identified by a readmission risk score, natural language processing and/or direct staff referral. Once identified, the patients were displayed on a list within the EMR to alert the social work navigator. The social work navigator then responded either in person or via phone and performed a comprehensive assessment with the patient. The assessment, in addition to a comprehensive social work assessment, had a hyper focus on SDOH screening domains which included transportation, financial, housing and food.

During the time frame from May 2022 to March 2023, 1,465 patients had a SDOH assessment completed, with 599 patients being able to be discharged from the ED. Of the 1465 patients, 312 screened positive for at least one SDOH need (21%). In February 2023, we implemented a natural language processing (NLP) program to better identify patients with SDOH needs for a SW navigator assessment. Through the use of NLP, 65% more patients were identified as appropriate for a SW navigator assessment. NLP was validated, correctly identifying patients on average 52.2% of the time.

This program demonstrates that utilizing a multimodal referral process is successful in identifying patients’ social determinant of health needs in the ED. Identifying these patients in the ED allows for intervention from the SW navigator and possible prevention of an unnecessary admission. Throughout the duration of the program, recruitment to fill social work navigator positions was challenging. As a result, limited hours of availability in the ED ultimately affected the volume of patients we were able to perform assessments on and provide interventions for. Additionally, we would like to expand this program to include a more in-depth look at the impact of the interventions on readmissions rates, and the long-term cost of care for our patients we serve. Overall, we recognize that providing social work assessment and intervention by addressing a patient’s SDOH needs is a valuable and positive contribution to our patients, community and healthcare system. Our current efforts will be to continue to build a more robust and comprehensive program to meet the needs of our emergency departments, patients and community we are so privileged to serve.


1. Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.


diane shifley

Diane Shifley, PT, DPTis a physical therapist. She received her BS from Western Illinois University with a major in biology emphasis in zoology and a minor in psychology. Following, she attended Midwestern University and graduated with a doctorate in physical therapy. Diane began her career in outpatient orthopedics and home health. In 2017, Diane joined NorthShore University HealthSystem and is now the senior director in the Cross Care Continuum with specialized focused on post-acute care.



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