Illustration of a hospital emergency room connected to the community, representing the social determinants of health.

Cracking the Code: How EDs Can Address the Root Causes of Frequent Visits

Kai Mendoza in Health & Wellness December 2025 • 5 min read.

"New research sheds light on the hidden factors driving emergency department utilization and reveals promising strategies for intervention."

Emergency departments across the country are facing increasing pressure, with overcrowding and long wait times becoming all too common. A significant contributor to this strain is the presence of frequent utilizers – patients who visit the ED multiple times within a short period. While many interventions have focused on managing these patients' immediate medical needs, emerging research suggests a more holistic approach is needed to truly address the root causes of their frequent visits.

Two studies presented at a recent research forum delve into the complex factors driving ED utilization, offering valuable insights for healthcare providers and policymakers alike. These studies explore the role of social determinants of health, the patient experience, and the effectiveness of intervention programs in reducing unnecessary ED visits.

This article will explore these key findings, translate complex research into actionable insights, and discuss the implications for improving patient care and alleviating the burden on emergency departments. By understanding the 'why' behind frequent ED visits, we can move towards more effective and sustainable solutions.

Beyond Medical Care: The Hidden Social Needs Driving ED Visits

Illustration of a hospital emergency room connected to the community, representing the social determinants of health.

One study (272), "Health-Related Social Needs in the Emergency Department: A Pilot Study," highlights the significant role of social determinants of health (SDOH) in driving ED utilization. Researchers screened patients in a large urban ED for five key domains: housing instability, food insecurity, transportation needs, utility needs, and interpersonal safety.

The results revealed that nearly one-third of ED patients reported at least one health-related social need (HRSN). Furthermore, Spanish-speaking patients were found to be at significantly higher risk of reporting HRSNs, even after adjusting for other factors. This suggests that language barriers and cultural factors may exacerbate existing social vulnerabilities, leading to increased ED utilization.

Housing Instability: 15% of patients reported concerns about their housing situation.
Food Insecurity: 17% struggled to access adequate food.
Transportation Needs: 11% lacked reliable transportation.
Utility Needs: 6% had difficulty paying for essential utilities.
Interpersonal Safety: 15% reported concerns about their safety.

These findings underscore the importance of integrating social needs screening into routine ED practice. By identifying patients facing challenges related to housing, food, transportation, or safety, healthcare providers can connect them with appropriate resources and support services. Addressing these underlying social needs can not only improve patients' overall well-being but also reduce their reliance on the ED for non-emergent care. Recognizing and addressing these HRSNs, especially among vulnerable populations, is vital for effective ED care.

Looking Ahead: A Call for Integrated and Patient-Centered Approaches

The studies highlighted in this article offer a compelling case for a more integrated and patient-centered approach to emergency care. Addressing the social determinants of health, improving communication with patients, and tailoring interventions to individual needs are crucial steps towards reducing unnecessary ED visits and improving the overall health of our communities.

Moving forward, healthcare systems should prioritize the development and implementation of comprehensive strategies that address both the medical and social needs of frequent ED utilizers. This may involve partnerships with community organizations, the integration of social workers into ED teams, and the development of culturally sensitive outreach programs.

By embracing a more holistic and proactive approach, we can transform emergency departments from overwhelmed crisis centers into hubs for comprehensive care and community well-being. This ultimately benefits both patients and the healthcare system as a whole, leading to healthier communities and more sustainable healthcare delivery.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

Everything You Need To Know

What are the main challenges that emergency departments are currently facing?

Emergency departments (EDs) are frequently overwhelmed by frequent visitors. These are individuals who repeatedly seek care at the ED within a short period. The article's focus is on identifying the underlying reasons behind these frequent visits, as they contribute significantly to ED overcrowding and increased wait times. The significance lies in understanding that addressing the root causes, rather than just treating immediate medical issues, is crucial for more effective solutions.

What are social determinants of health, and why are they important?

Social determinants of health (SDOH) are non-medical factors that influence health outcomes. Examples include housing instability, food insecurity, transportation needs, utility needs, and interpersonal safety. The research presented highlights that a significant portion of emergency department patients face one or more of these challenges. The importance of SDOH in this context is that addressing them can lead to a reduction in unnecessary ED visits. Ignoring these factors means missing opportunities to support patients' overall well-being and reduce their reliance on the ED for non-emergent care. The implications are that healthcare providers need to integrate social needs screening and connect patients with resources.

What percentage of patients reported health-related social needs in the study?

The study indicates that nearly one-third of emergency department patients reported at least one health-related social need (HRSN). The specifics include: Housing Instability (15%), Food Insecurity (17%), Transportation Needs (11%), Utility Needs (6%), and Interpersonal Safety (15%). The article highlights that these are not isolated issues, and the prevalence of these factors is substantial. This underscores the critical need to integrate social needs screening into routine ED practice. This approach allows healthcare providers to identify and address the root causes of frequent ED visits. Failing to do so means missing critical opportunities to connect patients with resources that address their core needs, potentially leading to recurring ED visits.

How do language barriers affect emergency department utilization?

Language barriers and cultural factors can significantly impact healthcare utilization. The research found that Spanish-speaking patients were at a significantly higher risk of reporting HRSNs, even after adjusting for other factors. This suggests that these barriers may exacerbate existing social vulnerabilities, leading to increased ED utilization. This is significant because it highlights the importance of culturally competent care and providing resources in multiple languages. The implications include the need for healthcare systems to address these disparities to ensure equitable access to care and reduce unnecessary ED visits among vulnerable populations.

What is the recommended approach for improving emergency care based on the article?

The article advocates for a more integrated and patient-centered approach to emergency care. This involves addressing the social determinants of health, improving communication with patients, and tailoring interventions to individual needs. This is important because it represents a shift from solely treating immediate medical needs to addressing the broader factors influencing a patient's health and utilization of the ED. The implications include the need for healthcare providers to adopt comprehensive strategies that consider both medical and non-medical factors. Such an approach not only improves patient care but also alleviates the burden on emergency departments by reducing unnecessary visits and promoting long-term health.