A Descriptive Study of Screening and Navigation on Health-Related Social Needs in a Safety-Net Hospital Emergency Department

Ruth Ellen Tubbs
Leah Warner
Bradley D. Shy
Christine Manikowski
Genie E. Roosevelt
Peer-Reviewed Article
June 2023


Emergency department (ED)-based social needs screening and referrals lead to a reduction in ED visits.


Hospital-based social needs screening and referrals have emerged as a critical strategy to address health-related social needs (HRSN) and improve health outcomes. In 2019, the Denver Health Emergency Department implemented an HRSN screening protocol during ED visits as part of its participation in the Center for Medicare and Medicaid Services' Accountable Health Communities model. Additional navigation services, involving referrals to community-based organizations and individualized follow-up, were offered to individuals with two or more ED visits in the past 12 months. This study assesses the impact of HRSN navigation on use of ED and inpatient services.


Among patients screening positive for at least one social need, those who received navigation services were 10 percent less likely to visit the ED within six months compared to those who opted out of such services (51 percent vs. 61 percent). The study did not find a statistically significant association between the receipt of navigation services and inpatient hospitalizations. During the study period, approximately one third of identified HRSN were resolved, with an additional one third still in process.


These findings suggest that HRSN screening and referral can reduce the likelihood of subsequent ED visits for individuals recently seen in the ED. The rate of successful resolution of HRSN, defined in this study as a successful link with a community-based organization addressing the need within one year, surpasses rates reported in many previous studies on HRSN referral programs. The authors attribute this difference primarily to the use of individualized navigation services.  

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