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

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Kai Mendoza in Health & Wellness October 2026 • 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.

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Social Factors and ED Use

The available sources do not provide a specific national count or rate of emergency department visits. The CDC’s NCHS FastStats page offers access to emergency-department statistics, while AHRQ’s free HCUPNet tool provides hospital inpatient and ED utilization information; national and state-level discharge datasets are also available for purchase. A study focused on older adults notes that multimorbidity is prevalent in this population and is associated with adverse outcomes, including high ED utilization, while the relationship between social determinants and ED visits among older adults with multimorbidity has received limited attention.

Screening Is Not Yet Standardized

Emergency departments do not consistently use standardized methods to screen for social determinants of health, and comprehensive SDOH risk assessments are not routinely conducted. The PRAPARE survey is described as a standardized framework for assessing patients’ social risks and assets. Housing instability, food insecurity, and transportation barriers are identified as relevant social needs, but standardized processes to assess and address them remain limited.

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.
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Screening and Care Connection Reviews

A 2024 article on social determinants of health in the emergency department was funded through the ResearchNB Summer Studentship program, which covered 16 weeks of undergraduate student research. A 2025 literature review describes ED-based SDOH screening as a promising way to identify and address individualized social needs across a broad patient population. It presents the potential goals of lowering ED readmissions and reducing health disparities.

Challenges in Measuring Social Drivers

Research on social determinants and ED use has examined different populations and levels of social factors. One study evaluated the relationship between social determinants and ED visits in the Medicaid Cohort of the District of Columbia. Another source notes that health systems struggle to incorporate social-determinant documentation into health records in forms usable for health-services research. A separate study examined both individual social needs and community-level SDOH using EHR data from July 2016 through June 2020, including their combined relationship to ED utilization.

Community Vulnerability and ED Screening

ED visits that could be managed in primary care settings are described as contributing to inefficiencies and increased healthcare costs. Adverse social determinants are associated with poorer health outcomes and are highly prevalent among ED patients. However, the screening efforts described in the source have often taken place in primary care rather than in emergency departments.

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.

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Expanding ED Social Needs Screening

The cited source reports that social determinants of health account for 80–90% of modifiable contributors to health outcomes and are associated with increased ED visits and hospital admissions. It also states that the Joint Commission and CMS have recently created new requirements to ensure patients are screened for SDOH. ED screening is presented as a way to identify patients with social needs and support whole-person care.

EDs as Healthcare Safety Nets

Emergency departments function as safety nets within the American healthcare system. The cited source says they care for many vulnerable populations, placing ED-based interventions in a broader context of social determinants’ implications for health outcomes in the United States.

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.

What the intervention results add up to

Taken together, the reported comparisons point toward fewer ED visits after or during interventions, but they do not show a uniform result across every design. The CATCH-ED comparison is explicitly uncertain, and the other reported differences should not be treated as proof of effectiveness on their own.[1] [2] [3]

Frequent ED use can occur among people with complex health needs, including chronic pain, multiple chronic conditions, or older age; the cited description links that complexity with multimorbidity, psychiatric comorbidities, and psychosocial issues.[4]

How the intervention evidence compares

The intervention literature is difficult to compare directly because definitions of frequent use varied and the risk of bias was moderate to high. A separate review also reported that visit reductions occurred in control groups in several randomized trials, and that implementation could require substantial resources without likely overall health-system cost savings.[1] [5]

A comparative cohort reported a decrease in mean ED visits, but the intervention involved a small, selective group and was not randomized, limiting how confidently that result can be attributed to the intervention.[5]

Case management can bundle crisis intervention, supportive therapy, care across settings, substance-abuse services, outreach, housing support, and multidisciplinary staffing. That breadth helps explain why implementation may carry substantial resource demands.[5]

What remains uncertain about frequent-use interventions

  • Do lower visit rates persist when frequent attendance is defined consistently across settings, given the variation in definitions and the moderate-to-high risk of bias reported in the review?[1]
  • Which elements of complex case management contribute most to lower use, and how do their resource demands relate to the reported changes in costs?[3] [5]

Sources

  1. Effectiveness of Interventions to Decrease Emergency Department Visits by Adult Frequent Users: A Systematic Review. (pubmed.ncbi.nlm.nih.gov)
  2. The effect of brief case management on emergency department use of frequent users in mental health: Findings of a randomized controlled trial (pmc.ncbi.nlm.nih.gov)
  3. ED-based care coordination reduces costs for frequent ED users. (pubmed.ncbi.nlm.nih.gov)
  4. A mapping review of interventions to address patients who frequently seek care in the emergency department (pmc.ncbi.nlm.nih.gov)
  5. Reducing Frequent Visits to the Emergency Department: A Systematic Review of Interventions (pmc.ncbi.nlm.nih.gov)

About this Article -

Written with AI assistance from published research, and reviewed by the Mystum team. See our About page for more information.

Everything You Need To Know

1

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.

2

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.

3

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.

4

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.

5

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.

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