Pediatric emergency department outreach: solving medical problems or revealing community solutions?

Low-acuity (LA) use of emergency departments (EDs) is often viewed as misuse or abuse. We designed a program to help users access services more efficiently. Community health workers (CHWs) functioned as health educators, screeners, and liaisons to care. A participatory curriculum emphasized medical problems. Qualitative ethnographic methods were used for formative evaluation. Ninety families received regular visits from CHWs. Original system-oriented objectives and methods did not fit community needs. Instead, information was gathered regarding service utilization patterns: (1) families mistrusted primary and preventive care, reporting frequent discrimination and humiliation; (2) a primarily biomedical prioritization did not match families' need hierarchies; (3) complex demands of poverty made other uses of the system challenging; (4) primary care services were frequently avoided; and (5) the ED was often preferred. Intangible psychosocial factors and practical complexities of poverty were powerful promoters of LA visits. Families were creative strategists, viewing LA visits as rational use, not misuse, of a challenging system.