I recently cared for a young patient who was hospitalized for dehydration and acute gastroenteritis due to 3 infectious pathogens. Her course was complicated by a urinary tract infection, and she also had friction blisters with peeling skin on the soles of her feet. She and her family had emigrated from Venezuela 1 week before her presentation to our emergency department (ED). They traveled to the United States on foot and were held at a detention facility on the US-Mexico border for a brief period of time before making their way to stay with extended family in New York City. After treating her acute conditions, we performed several screenings and vaccinations and connected the family to community services and primary care.1
During a separate shift in the ED, I took care of an 11-year-old girl who presented with tooth pain due to a dislodged filling. She had a low BMI, and to my surprise, her cardiac examination revealed a harsh murmur, which turned out to be a large ventricular septal defect at risk for Eisenmenger’s Syndrome. During her hospitalization for surgical management, I learned about the trauma she and her family faced that led to their unanticipated migration, which included an urgent departure from their home country and several border crossings by foot. Toward the end of her stay, her provider team and I decided that I would serve as her pediatrician in my resident continuity clinic to deliver appropriate immigrant-focused care and to help the family navigate the health care system.
Providing care for immigrant children is a collaborative effort that includes coordination between all touchpoints from primary care offices, emergency rooms, and inpatient units to schools and community centers. The American Academy of Pediatrics defines immigrant children as those born outside the United States or to noncitizen parents.2 In 2021, 2.5 million US children (3% to 4%) were foreign-born, and it is estimated that 18% of the US population will be foreign-born by 2065.3
Asylum-seekers have arrived in New York City and other non-border cities by the thousands, many of them seeking refuge from political and humanitarian crises in South and Central America. Although some children may undergo an initial medical evaluation and treatment in government-operated border facilities, this occurs inconsistently as immigration increases, capacity is limited, and some migrants seek unauthorized points of entry.4 Asylees have relocated to non-border cities both willingly and unwillingly; however, many may be bused unwillingly to cities where they may not have any family or friends, thus creating increased vulnerability.5 Regardless of political forces and border policies, hospital-based pediatric providers play an important role in addressing the health of migrant children.
Migrant children may not seek evaluation and treatment in primary care offices due to lack of insurance. Those eligible for insurance still face limited hours of service delivery, limited knowledge of available care modalities, limited transportation, and the fear of registering in a system funded by public dollars.6 They are less likely to seek primary care than non-migrants, and there has been a shift toward more ED visits.7 Immigrant children are more likely to be hospitalized and have a more advanced stage of illness.8 The hospital setting may represent an immigrant child’s first interaction with our health care system. Given the availability of time and centralized resources, this presents and opportunity to address needs of children and families who may be less familiar with preventive primary care models. Based on our experiences and established best practices, we provide an approach that may empower hospital-based providers to optimize care for recently immigrated children. (AAP Resource: https://downloads.aap.org/AAP/PDF/Supporting_Immigrant_Children_Pediatrician_Resources_TIPS_2019.pdf).
Approach Families With Cultural Humility
Language differences and a lack of cultural humility among providers are major barriers to migrants seeking care.6 Immigrants, especially those from rural and indigenous communities, may have had limited to no care at hospitals or medical institutions, and thus, treating them with dignity and respect is vital to building trust and a therapeutic relationship. Providers should use recommended interpreter services when exploring medical histories and the social circumstances around migration that may lead to acute conditions in children.
Recommendations
Train providers in the practice of trauma-informed care. Immigrant children are at increased risk for anxiety, depression, and posttraumatic stress disorder as a result of adverse childhood experiences that may have occurred prior to departure, in transit, or on arrival.9 They may also experience fear, discrimination, acculturation stress, and stressors related to social determinants of health and the illness for which they are seeking hospital care.1 Through repeated interactions over the course of a hospital stay, consistent providers may be able to build a relationship to elicit mental health concerns. Interprofessional workshops including behavioral health professionals, social workers, and former patients, have been used as a means to train providers in specific tactics that can be used in the inpatient setting to allow providers to work with children and families in a sensitive manner while minimizing retraumatization.10
Elicit an appropriate migration history. Hospital settings are typically equipped with interpreter services including languages of limited diffusion, and thus a detailed history may be obtained without reliance upon ad-hoc interpreters.11,12 With a prompt as simple as “Tell me about your journey,” clinicians and social workers may partner to gather important insights that can guide evaluation and treatment. There are many reasons for forced or selective migration from so-called “push and pull forces,” and one should not assume motivation based on an individual’s home country. It is important to understand that patients and families may not share details right away, or at all, during their hospitalization, but providing a safe environment may facilitate sharing.
Empower families and address fear/mistrust. Immigrant families face multiple barriers in accessing care due to mistrust of a medical system that marginalizes and excludes them due to immigration status and “legality.”13 A hospital stay presents an opportunity to boost family empowerment and trust in the healthcare system to mitigate future inequity.1 Providers should recognize that families may have cultural deference and be reluctant to ask questions or challenge the medical team. Inpatient teams should practice cultural humility and ask families if there are cultural practices or treatments that the family utilizes. In addition, teams should ask if there are specific individuals in the community that should be involved in the care team. Partnering with social workers, community health workers, cultural brokers, and family advocates can also help to facilitate adaptation and integration.15,16
Tools for Hospital-Based Providers
The hospital setting can facilitate access to resources that may be more difficult for new families to obtain in the outpatient setting such as laboratory tests, imaging, presumptive therapies, and language-concordant services.
Recommendations
Perform screenings and administer vaccines & presumptive therapies. Depending on a child’s risk factors, there may be up to 18 recommended screenings; hospital-based providers can coordinate recommended screenings and administer vaccines during an inpatient stay to aid our outpatient colleagues.1 Most recently immigrated children will require updated vaccinations in order to enroll in school.17 Additionally, the administration of single-dose presumptive therapies (e.g., albendazole) can eliminate the need for families to navigate outpatient pharmacies.
Utilize EMR-based acronym expanders and order sets. These evidence-based strategies help providers more easily adhere to recommended historical questions, screenings, presumptive therapies, vaccinations, and referrals.18
Employ evidence-based health literacy approaches when providing education to families. Migrants are at high risk for limited health literacy. Evidence-based strategies such as chunking, teach-back, and show-back have been linked to better outcomes and a hospitalization presents opportunities for repetition and reinforcement from a multidisciplinary team.19 Teams may also wish to tailor communication to a family’s preference, including use of visual aids, electronic messages, or printed documents.
Connect Families to Providers and Resources at Discharge
Hospital-based social workers and care managers can help families obtain child health insurance and connections to myriad community agencies that may assist families in addressing social determinants of health. Providers should identify and partner with pediatricians in the community that have experience caring for immigrant children and can bridge the process of evaluation and treatment. If feasible, provider teams may include the pediatrician remotely in discharge counseling to establish name/voice recognition for the patient/family.
Recommendations
Multidisciplinary inpatient teams should develop migrant-specific discharge criteria that incorporate the following:
Refer to legal aid when available. Legal support, through non-profit agencies, pro-bono services, or clinical-community partnerships, assists families in stabilizing immigration status and ensuring the child has a caregiver capable of providing authorization for any necessary medical care or services.17,20
Connect to community resources. Community-based organizations (CBO), social service agencies, mutual aid groups, immigrant rights organizations, and volunteer coalitions may assist families in addressing social determinants of health, such as food, housing, transportation, and education/employment. Enrollment in school can be difficult because of overcrowding and a lack of bilingual services.17 CBOs may also connect families to cultural activities and a support system to ease the abrupt transition for children. If there is a central agency caring for immigrant children locally, direct communication with the agency can provide targeted and specific resources for a family.
Enroll in child health insurance programs. Enrollment in a Medicaid program or charity care is essential to establishing access to care. As of January 2023, 9 states/territories provide insurance to all children <18 years of age (California, Illinois, Maine, New Jersey, New York, Oregon, Vermont, Washington, and Washington DC); Connecticut provides insurance to all children <12 years of age. However, among Latino immigrant children federally eligible for Medicaid/CHIP, just 64% participated, indicating barriers to enrollment.21 Providers may also pursue charity care, free clinics, federally qualified health centers, and other options at the local and/or state levels.
Bridge to a medical home. One-quarter of immigrant children live below the federal poverty level, and their families are more greatly affected by the indirect cost of missing/losing work to attend appointments.3 Bundling services in 1 visit in the medical home is essential to overcoming limited hours for service delivery/capacity.5
Conclusions
Hospital providers play an important role in the evaluation and treatment of immigrant children and serve as a safety net. In areas with limited outpatient resources, the hospital may be the ideal locale to provide comprehensive care. Providers should be aware of local laws, insurance options, and community resources/partnerships. By enacting these specific and achievable recommendations, we can improve the delivery of high-quality and comprehensive care while ensuring the continuity of care through bridging connections to community services and a medical home. These suggestions can be executed even in short hospitalizations and need not prolong the length of stay.22 Immigration is a complicated issue, but these actions can help simplify the process for patients, families, and health care providers alike.
Acknowledgment
We wish to acknowledge Dodi Meyer, MD, for reviewing our manuscript before submission.
Drs Berlant and Brighton drafted the initial manuscript and critically reviewed and revised the manuscript; Ms Estrada Guzman critically reviewed and revised the manuscript; Dr Banker conceptualized and supervised the design of the manuscript and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
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