When high pressure, system constraints, and a social justice mission collide: A socio-structural analysis of emergency department social work services.

The emergency department (ED) can be a critical intervention point for many patients with multifaceted needs. Social workers have long been part of interdisciplinary ED teams. This study aimed to contribute to the limited understanding of social worker-patient interactions and factors influencing social work services in this setting. This paper reports a qualitative content analysis of social work medical record notes (N = 1509) of services provided to trauma patients in an urban, public, level 1 trauma center and an in-depth analysis of semi-structured interviews with ED social workers (N = 10). Eight major social work roles were identified: investigator, gatekeeper, resource broker, care coordinator, problem solver, crisis manager, advocate, discharge planner. Analyses revealed a complex interplay between ED social work services and multi-layered contexts. Using a social-ecological framework, we identified the interactions between micro or individual level factors, mezzo or local system level factors and macro environmental and systemic factors that play a role in ED interactions and patient services. Macro-level contextual influences were socio-structural forces including socioeconomic barriers to health, social hierarchies that reflected power differentials between providers and patients, and distrust or bias. Mezzo-level forces were limited resources, lack of healthcare system coordination, a challenging hierarchy within the medical model and the pressure to discharge patients quickly. Micro-level factors included characteristics of patients and social workers, complexity of patient stressors, empathic strain, lack of closure and compassion. All of these forces were at play in patient-social worker interactions and impacted service provision. Social workers were at times able to successfully navigate these forces, yet at other times these challenges were insurmountable. A conceptual model of ED social work and the influences on the patient-social worker interactions was developed to assist in guiding innovative research and practice models to improve services and outcomes in the complex, fast-paced ED.

The Role of Social Work in Providing Mental Health Services and Care Coordination in an Urban Trauma Center Emergency Department.

OBJECTIVE: This study examined the role of emergency department (ED) social workers and identified predictors of receipt of social work services and length of ED stay. METHODS: Comprehensive reviews were conducted of medical records of all patients (N=49,354) treated in a level 1 trauma center ED from January 1, 2012, to March 31, 2013. Content analysis of chart notes was used to categorize the types of social work services provided. Poisson regression was used to assess associations between demographic and clinical characteristics, receipt of social work services, and length of ED stay. RESULTS: Social work services were provided to 18,532 (38%) patients. Most were mental health services (54%), followed by care coordination (31%) and material support or other referrals (15%). Patients seen by social workers had complex presentations, involving mental disorder diagnoses (18%), substance use disorder diagnoses (29%), comorbid diagnoses (32%), and injuries (51%); a quarter of patients had multiple ED visits (26%). In adjusted regression analysis, females (relative risk [RR]=1.15), patients not discharged home (RR=1.44), and those with two or more comorbid diagnoses (RR=1.80), injuries due to assault (RR=1.37), and traumatic brain injury (RR=1.20) were more likely to receive social work services. Such services were associated with an increased length of ED stay (RR=1.34). CONCLUSIONS: Social workers provided services to patients with multifaceted needs resulting from complex presentations. Provision of social work services modestly increased length of ED stay. Triage algorithms are needed to target efficiencies, systematize provision of ED social work services, and improve access to services for all patients.

The role of intercalating residues in chromosomal high-mobility-group protein DNA binding, bending and specificity.

Ubiquitous high-mobility-group (HMGB) chromosomal proteins bind DNA in a non-sequence- specific fashion to promote chromatin function and gene regulation. Minor groove DNA binding of the HMG domain induces substantial DNA bending toward the major groove, and several interfacial residues contribute by DNA intercalation. The role of the intercalating residues in DNA binding, bending and specificity was systematically examined for a series of mutant Drosophila HMGB (HMG-D) proteins. The primary intercalating residue of HMG-D, Met13, is required both for high-affinity DNA binding and normal DNA bending. Leu9 and Tyr12 directly interact with Met13 and are required for HMG domain stability in addition to linear DNA binding and bending, which is an important function for these residues. In contrast, DNA binding and bending is retained in truncations of intercalating residues Val32 and Thr33 to alanine, but DNA bending is decreased for the glycine substitutions. Furthermore, substitution of the intercalating residues with those predicted to be involved in the specificity of the HMG domain transcription factors results in increased DNA affinity and decreased DNA bending without increased specificity. These studies reveal the importance of residues that buttress intercalating residues and suggest that features of the HMG domain other than a few base-specific hydrogen bonds distinguish the sequence-specific and non-sequence-specific HMG domain functions.