The categorisation of vulnerable hospital patients as “socially admitted” has been identified as potentially obstructing their medical treatment, as indicated by recent research published in the Canadian Medical Association Journal (CMAJ). Emergency departments often serve as a last resort for socially vulnerable individuals who, despite not presenting with acute or newly arising medical conditions, demonstrate remarkable resilience in seeking care due to a breakdown in support systems or the inability of themselves or their families to manage home-based living conditions. Such individuals are colloquially referred to as “social admissions,” and various labels such as “orphan patient” or “failure to cope” have been applied to them.

Dr. Jasmine Mah, an internal medicine resident focusing on geriatrics at Dalhousie University in Halifax, Nova Scotia, and co-authors highlight that “social admission” remains an under-researched area within healthcare. These patients, often perceived by healthcare providers as not acutely ill, face significantly higher in-hospital mortality rates ranging from 22.2% to 34.9%. Contributing factors may include under-triaging in emergency departments due to inadequate recognition of atypical clinical presentations and delays in timely assessments.

Moreover, there is a risk of misdiagnosis or the development of acute illnesses during hospitalisation. Researchers conducted a qualitative study exploring healthcare providers’ perspectives on “social admissions” in Nova Scotia to gain deeper insights into this patient category. They identified nine overarching themes, including stigma, prejudices such as ageism, wait lists, and other factors influencing perceptions and approaches towards caring for these patients.

The authors emphasise the detrimental impact of labelling patients as “socially admitted” or “orphan patients” (as described in the study hospital), citing instances where such labels lead to incorrect assumptions about medical needs and cognitive abilities. This, in turn, hinders efforts to identify and treat underlying medical issues promptly.

The study reveals that such labelling adversely affects patient health and undermines healthcare providers’ morale. Many providers express conflicted feelings about delivering care to these patients, often feeling that others should handle such care. This attitude risks relegating the care of “socially admitted” patients to team members who may lack sufficient experience in recognising evolving medical conditions or advocating effectively for clinical reassessments when necessary. This hierarchical approach underscores a detachment from the specific needs of this patient demographic.

In response to these findings, the authors passionately advocate for structural reforms within healthcare systems to enhance care delivery for vulnerable populations. They call for a reconsideration of current organisational structures and hierarchies, aiming to eliminate barriers that impede optimal care for socially vulnerable individuals. By doing so, they believe that we can create a healthcare system that is more inclusive, compassionate, and effective in meeting the needs of all patients.

In a related editorial published in CMAJ, Dr Catherine Varner, a deputy editor and emergency medicine physician, along with co-authors Dr Andrew Boozary, a primary care physician, and Dr Andreas Laupacis, editor of CMAJ, argue for a reframing of the issue as a policy failure rather than a personal one. They criticise policies such as Ontario’s alternate level of care policies, which penalise hospitals and patients for occupying beds despite no longer requiring acute care. Such punitive measures, they argue, not only cause distress among patients, families, and providers but also fail to address the root causes of hospital overcrowding.

Instead, they propose embedding collaborative and supportive programmes within healthcare settings, such as multidisciplinary geriatric teams in emergency departments and health teams dedicated to supporting vulnerable populations. These initiatives aim to enhance the management of frail older patients and provide comprehensive support to socially vulnerable individuals, restoring dignity and improving outcomes in healthcare delivery.

Ultimately, the authors stress the paramount importance of addressing structural factors contributing to health disparities as systemic failures rather than individual shortcomings. They call for a paradigm shift towards policies that not only address the complex needs of vulnerable patient populations but also uphold and restore human dignity. This, they argue, is the key to alleviating moral distress among healthcare providers and improving overall healthcare outcomes.

More information: Jasmine C. Mah et al, Managing “socially admitted” patients in hospital: a qualitative study of health care providers’ perceptions, Canadian Medical Association Journal. DOI: 10.1503/cmaj.231430

Journal information: Canadian Medical Association Journal