COVID-19 Disruptions to Social Care Delivery: A Qualitative Study in Two Large, Safety-Net Primary Care Clinics.

BACKGROUND: Social care integration refers to the incorporation of activities into health systems that assist patients with health-related social needs (HRSNs) that negatively impact the health outcomes of their patients, such as food insecurity or homelessness. Social care integration initiatives are becoming more common. The COVID-19 pandemic strained health systems while simultaneously increasing levels of unmet social needs. OBJECTIVE: To describe the effects of the COVID-19 pandemic on established social care delivery in a primary care setting. DESIGN: We used qualitative semi-structured interviews of stakeholders to assess barriers and facilitators to social care delivery in the primary care setting during the COVID-19 health emergency. Data was analyzed using a hybrid inductive/deductive thematic analysis approach with both the Consolidated Framework for Implementation Research (CFIR) and the Screen-Navigate-Connect-Address-Evaluate model of social care integration. SETTING: Two safety-net, hospital-based primary care clinics with established screening for food insecurity, homelessness, and legal needs. PARTICIPANTS: Six physicians, six nurses, six members of the social work team (clinical social workers and medical case workers), six community health workers, and six patients (total N = 30) completed interviews. RESULTS: Four major themes were identified. (1) A strained workforce experienced challenges confronting increased levels of HRSNs. (2) Vulnerable populations experienced a disproportionate negative impact in coping with effects of the COVID-19 pandemic on HRSNs. (3) COVID-19 protections compounded social isolation but did not extinguish the sense of community. (4) Fluctuations in the social service landscape led to variable experiences. CONCLUSIONS: The COVID-19 pandemic disrupted established social care delivery in a primary care setting. Many of the lessons learned about challenges to social care delivery when health systems are strained are important considerations that can inform efforts to expand social care delivery.

A Mixed Methods Evaluation of Interventions to Meet the Requirements of California Senate Bill 1152 in the Emergency Departments of a Public Hospital System.

Policy Points Clarifications to Senate Bill (SB) 1152 are necessary to address the differences between inpatient and emergency department (ED) discharge processes, determine how frequently an ED must deliver the SB 1152 bundle of services to a single patient, and establish expectations for compliance during off-hours when social services are unavailable. Because homelessness cannot be resolved in a single ED visit, the state should provide funding to support housing-focused case workers that will follow patients experiencing homelessness (PEH) through the transition from temporary shelters to permanent supportive housing. Medi-Cal could fund the delivery of the SB 1152 bundle of services to defray the costs to public hospitals that provide care for high numbers of PEH. California legislators should consider complementary legislation to increase funding for shelters so that sufficient capacity is available to accept PEH from EDs and hospitals, and to fund alternative strategies to prevent poverty and the upstream root causes of homelessness itself. CONTEXT: Prompted by stories of "patient dumping," California enacted Senate Bill (SB) 1152, which mandates that hospitals offer patients experiencing homelessness (PEH) a set of resources at discharge to ensure safety and prevent dumping. METHODS: To evaluate interventions to meet the requirements of SB 1152 across three emergency departments (EDs) of a Los Angeles County public hospital system with a combined annual census of 260,000 visits, we used an explanatory sequential mixed methods approach, focusing first on quantitative evaluation and then using information from qualitative interviews to explain the quantitative findings. FINDINGS: In total, 2.9% (1,515/52,607) of encounters involved PEH. Documentation of compliance with the eight required components of SB 1152 was low, ranging from 9.0% to 33.9%. Twenty-five provider interviews confirmed support for providing assistance to PEH in the ED, but the participants described barriers to compliance, including challenges in implementing universal screening for homelessness, incongruity of the requirements with the ED setting, the complexity of the patients, and the limitations of SB 1152 as a health policy. CONCLUSIONS: Despite operationalizing universal screening for homelessness, we found poor compliance with SB 1152 and identified multiple barriers to implementation.

Provider perspectives on emergency department initiation of medication assisted treatment for alcohol use disorder.

BACKGROUND: Alcohol use disorder (AUD) is ubiquitous and its sequelae contribute to high levels of healthcare utilization, yet AUD remains undertreated. The ED encounter represents a missed opportunity to initiate medication assisted treatment (MAT) for patients with AUD. The aims of this study are to identify barriers and facilitators to the treatment of AUD in the ED, and to design interventions to address identified barriers. METHODS: Using an implementation science approach based on the Behavior Change Wheel framework, we conducted qualitative interviews with staff to interrogate their perspectives on ED initiation of AUD treatment. Subjects included physicians, nurses, nurse practitioners, clinical social workers, and pharmacists. Interviews were thematically coded using both inductive and deductive approaches and constant comparative analysis. Themes were further categorized as relating to providers' capabilities, opportunities, or motivations. Barriers were then mapped to corresponding intervention functions. RESULTS: Facilitators at our institution included time allotted for continuing education, the availability of clinical social workers, and favorable opinions of MAT based on previous experiences implementing buprenorphine for opioid use disorder. Capability barriers included limited familiarity with naltrexone and difficulty determining which patients are candidates for therapy. Opportunity barriers included the limited supply of naltrexone and a lack of clarity as to who should introduce naltrexone and assess readiness for change. Motivation barriers included a sense of futility in treating patients with AUD and stigmas associated with alcohol use. Evidence-based interventions included multi-modal provider education, a standardized treatment algorithm and order set, selection of clinical champions, and clarification of roles among providers on the team. CONCLUSIONS: A large evidence-practice gap exists for the treatment of AUD with Naltrexone, and the ED visit is a missed opportunity for intervention. ED providers are optimistic about implementing AUD treatment in the ED but described many barriers, especially related to knowledge, clarification of roles, and stigma associated with AUD. Applying a formal implementation science approach guided by the Behavior Change Wheel allowed us to transform qualitative interview data into evidence-based interventions for the implementation of an ED-based program for the treatment of AUD.

A Pragmatic Assessment of Google Translate for Emergency Department Instructions.

BACKGROUND: Because many hospitals have no mechanism for written translation, ED providers resort to the use of automated translation software, such as Google Translate (GT) for patient instructions. A recent study of discharge instructions in Spanish and Chinese suggested that accuracy rates of Google Translate (GT) were high. STUDY OBJECTIVE: To perform a pragmatic assessment of GT for the written translation of commonly used ED discharge instructions in seven commonly spoken languages. METHODS: A prospective assessment of the accuracy of GT for 20 commonly used ED discharge instruction phrases, as evaluated by a convenience sample of native speakers of seven commonly spoken languages (Spanish, Chinese, Vietnamese, Tagalog, Korean, Armenian, and Farsi). Translations were evaluated using a previously validated matrix for scoring machine translation, containing 5-point Likert scales for fluency, adequacy, meaning, and severity, in addition to a dichotomous assessment of retention of the overall meaning. RESULTS: Twenty volunteers evaluated 400 google translated discharge statements. Volunteers were 50% female and spoke Spanish (5), Armenian (2), Chinese (3), Tagalog (4), Korean (2), and Farsi (2). The overall meaning was retained for 82.5% (330/400) of the translations. Spanish had the highest accuracy rate (94%), followed by Tagalog (90%), Korean (82.5%), Chinese (81.7%), Farsi (67.5%), and Armenian (55%). Mean Likert scores (on a 5-point scale) were high for fluency (4.2), adequacy (4.4), meaning (4.3), and severity (4.3) but also varied. CONCLUSION: GT for discharge instructions in the ED is inconsistent between languages and should not be relied on for patient instructions.

Language assistance for limited English proficiency patients in a public ED: determining the unmet need.

BACKGROUND: Many patients who present to public Emergency Departments (EDs) have Limited English Proficiency (LEP). LEP patients have worse understanding of their conditions and high rates of ED recidivism. LEP patients are entitled to language assistance under Title IV of the 1964 Civil Rights Act. The objective of this study is to characterize the unmet need for language assistance in a public ED. METHODS: Retrospective chart review of 48 h of successive patient encounters in a public ED. Registration workers asked each patient their preferred language and whether they would like an interpreter. On recent implementation of a new electronic health record (EHR), however, providers were unable to see the responses recorded. When discovered, this created a natural experiment to compare patient request for language assistance with documented practice of the providers who were unaware of the patient's stated preference at registration. The study was set in a public, urban ED, annual census of 50,000 visits, with language assistance services available 24/7 via video units and phone line. The subjects included all patients presenting to the ED for a 48-h period. Those with altered level of consciousness and those who left before being seen were excluded. Age, race, ethnicity, preferred language, preference for language assistance, status of the provider as certified bilingual, documentation of language assistance use, type of language assistance used (video, phone, bilingual staff or ad hoc) were captured. Descriptive statistics were used with proportions and 95% CIs to describe the unmet need. RESULTS: In total, 253 encounters met inclusion criteria. Mean age was 41 years, 201/253 (79.5%) were Hispanic or Latino, and 134/253 (53%) preferred to use a language other than English (97% Spanish, 2% Armenian and 0.8% Tagalog). Of the 110/253 (43%) patients requesting an interpreter, 12/110 (10.9%) were seen by a certified bilingual provider and 5/110 (4.6%) had written documentation by the primary provider that language assistance was used. The calculated unmet need for spoken language assistance was 93/110 (84.5%) of patients requesting language assistance or 93/253 (36.8, 95%CI 31-42.9%) of total ED patients. CONCLUSIONS: In this public ED, there is a large unmet need for language assistance for LEP patients.

Initiating Diagnostic Studies on Patients With Abdominal Pain in the Waiting Room Decreases Time Spent in an Emergency Department Bed: A Randomized Controlled Trial.

STUDY OBJECTIVE: The effect of clinician screening of patients in the emergency department (ED) waiting room is unclear. This study aims to determine the effect of initiating laboratory and imaging studies from the ED waiting room on time in a bed, total ED time, and likelihood of patients leaving before completion of service. METHODS: This was a prospective, randomized, controlled trial evaluating 1,659 nonpregnant adults with a chief complaint of abdominal pain, conducted in a public hospital ED when all ED beds were occupied and patients were in the waiting room awaiting definitive evaluation. After a brief screening examination, stable patients were randomized to either rapid medical evaluation (RME)+waiting room diagnostic testing (WRDT) or RME-only groups. Patients randomized to the RME+WRDT group had laboratory and imaging studies ordered at the discretion of the screening provider while in the waiting room. The primary outcome was time in an ED bed. Secondary outcomes were total ED time and rate of leaving before completion of service. Linear and logistic regression models were used to compare outcomes between groups. RESULTS: Between July 2014 and May 2015, 1,659 patients completed the study, 848 patients in the RME+WRDT group and 811 in the RME-only group. Baseline demographic characteristics were similar between groups. Patients in the RME+WRDT group had a significantly shorter mean time in an ED bed than the RME-only group, 245 minutes compared with 277 minutes (adjusted difference of 31 minutes; 95% confidence interval [CI] 16 to 46 minutes). The RME+WRDT group also had significantly shorter mean total ED time from arrival to disposition than the RME-only group, 460 minutes compared with 504 minutes (adjusted difference 42 minutes; 95% CI 22 to 63 minutes). Of the 1,659 patients enrolled, 181 left before completion of service: 78 of 848 patients (9%) in the RME+WRDT group compared with 103 of 811 (13%) in the RME-only group (difference 3.5%; 95% CI 0.5% to 6.5%). By the end of their ED visit, patients in the RME+WRDT group had significantly more types of diagnostic studies ordered than those in the RME-only group, 2.59 versus 2.03 total unique test categories by location ordered (difference 0.56; 95% CI 0.44 to 0.68). CONCLUSION: Initiating diagnostic testing in the waiting room reduced time spent in an ED bed, total ED time, and rates of leaving before completion of service. For clinicians screening patients in the waiting room, initiating diagnostic evaluations may improve throughput in crowded EDs.

Differences in test ordering between nurse practitioners and attending emergency physicians when acting as Provider in Triage.

STUDY OBJECTIVES: To compare diagnostic test ordering practices of NPs with those of physicians in the role of Provider in Triage (PIT). METHODS: This was a secondary analysis of data from a prospective RCT of waiting room diagnostic testing, where 770 patients had diagnostic studies ordered from the waiting room. The primary outcome was the number of test categories ordered by provider type. Other outcomes included total tests ordered by the end of ED stay, and time in an ED bed. We compared variables between groups using t-test and chi-square, constructed logistic regression models for individual test categories, and univariate and multivariate negative binomial models. RESULTS: Physicians ordered significantly more diagnostic test categories than NPs (1.75 vs. 1.54, p<0.001). By the end of their ED stay, there was no significant difference in total test categories ordered between provider type: physician 2.67 vs. NP 2.53 (p=0.08), using a nonbinomial model, incidence rate ratio (IRR) 1.07 (0.98-1.17). Patient time in an ED bed was not significantly different between physicians and NPs (NP 244min, SD=133, Physicians 248min, SD=152) difference 4min (-24.3-16.1) p=0.688. CONCLUSION: NPs in the PIT role ordered slightly less diagnostic tests than attending physicians. This slight difference did not affect time spent in an ED bed. By the end of the ED stay, there was no significant difference in total test categories ordered between provider types. PIT staffing with NPs does not appear to be associated with excess test ordering or prolonged ED patient stays.

Utilization and perceptions of language assistance services by medical trainees: a pathway to language certification.

Background: Access to language assistance is a patient's right under federal law. Despite this, underuse of language services persists. Objective: The aim of this study was to explore the interest in obtaining bilingual certification and to describe perspectives on language services by resident physicians. Methods: Between May and August 2021, we conducted a cross-sectional survey of residents at a public, urban hospital serving mostly patients with limited English proficiency (LEP). We assessed resident perspectives on language services, exposure to language-related trainings, non-English language (NEL) skills, and interest in bilingual certification. Results: A total of 214 residents of 289 completed the survey (a 74% response rate). Of the 95 residents who used their NEL for patient care, 65 (68%) would be interested in bilingual certification. Sixty-nine (33%), 65 (31%), and 95 (45%) residents disagreed or strongly disagreed with being satisfied with the language services available, convenience, and sufficient equipment, respectively. Furthermore, 28 (13%) disagreed or strongly disagreed that they could achieve bi-directional communication with LEP patients. Conclusions: Over a quarter of the residents expressed interest in bilingual certification and were likely to pass the certification exam. Many reported using their own NEL skills without certification and held negative views on services and trainings.

2023 Inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium.

Introduction: This article provides an overview of presentations and discussions from the inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium. Methods: The symposium brought together esteemed experts from various disciplines to explore models for translating evidence-based interventions into practice. Results: The symposium highlighted the importance of disruptive innovation in healthcare, the need for multi-stakeholder engagement, and the significance of family and community involvement in healthcare interventions. Conclusions: The article concluded with a call to action for advancing healthcare delivery science to achieve health equity.

Patient perspectives on emergency department initiation of medication for alcohol use disorder.

OBJECTIVE: Alcohol use disorder (AUD) is a leading cause of preventable death and is a frequent diagnosis in the emergency department (ED). Treatment in the ED, however, typically focuses on managing the sequelae of AUD, such as acute withdrawal, rather than addressing the underlying addiction. For many patients, these ED encounters are a missed opportunity to connect with medication for AUD. In 2020, our ED created a pathway to offer patients with AUD treatment with naltrexone (NTX) during their ED visit. The aim of this study was to identify what barriers and facilitators patients perceive to NTX initiation in the ED. METHODS: Adopting the theoretical framework of the behavior change wheel (BCW), we conducted qualitative interviews with patients to elicit their perspectives on ED initiation of NTX. Interviews were coded and analyzed using both inductive and deductive approaches. Themes were categorized according to patients' capabilities, opportunities, and motivations. Barriers were then mapped through the BCW to design interventions that will improve our treatment pathway. RESULTS: Twenty-eight patients with AUD were interviewed. Facilitators of accepting NTX included having recently experienced sequelae of AUD, rapid management of withdrawal symptoms by the ED provider, having a choice between intramuscular and oral formulations of the medication, and experiencing positive interactions in the ED that destigmatized the patient's AUD. Barriers to accepting treatment included lack of provider knowledge about NTX, dependence on alcohol as self-treatment for psychiatric trauma and physical pain, perceived discriminatory treatment and stigma about AUD, aversion to potential side effects, and lack of access to continued treatment. CONCLUSIONS: Initiation of treatment of AUD with NTX in the ED is acceptable to patients and can be facilitated by knowledgeable ED providers who create a destigmatizing environment, effectively manage withdrawal symptoms, and connect patients to providers who will continue treatment.

Implementation and Impacts of California Senate Bill 1152 on Homeless Discharge Protocols.

Introduction: In recent decades, there has been a growing focus on addressing social needs in healthcare settings. California has been at the forefront of making state-level investments to improve care for patients with complex social and medical needs, including patients experiencing homelessness (PEH). Examples include Medicaid 1115 waivers such as the Whole Person Care pilot program and California Advancing and Innovating Medi-Cal (CalAIM). To date, California is also the only state to have passed a legislative mandate to address concerns related to the hospital discharge of PEH who lack sufficient resources to support self-care. To this end, California enacted Senate Bill 1152 (SB 1152), a unique legislative mandate that requires hospitals to standardize comprehensive discharge processes for PEH by providing (and documenting the provision of) social and preventive services. Understanding the implementation and impact of this law will help inform California and other states considering legislative investments in healthcare activities to improve care for PEH. Methods: To understand health system stakeholders' perceived impact of SB 1152 on hospital discharge processes and key barriers and facilitators to SB 1152's implementation, we conducted 32 semi-structured interviews with key informants across 16 general acute care hospitals in Humboldt and Los Angeles counties. Study data were coded and analyzed using thematic analysis informed by the Consolidated Framework for Implementation Research. Results: Participants perceived several positive impacts of SB 1152, including streamlined services, increased accountability, and more staff awareness about homelessness. In parallel, participants also underscored concerns about the law's limited scope and highlighted multiple implementation challenges, including lack of clarity about accountability measures, scarcity of implementation supports, and gaps in community resources. Conclusion: Our findings suggest that SB 1152 was an important step toward the goal of more universal safe discharge of PEH. However, there are also several addressable concerns. Recommendations to improve future legislation include adding targeted funding for social care staff and improving implementation training. Participants' broader concerns about the parallel need to increase community resources are more challenging to address in the immediate term, but such changes will also be necessary to improve the overall health outcomes of PEH.

Physical fitness cannot be used to predict the likelihood of acute coronary syndromes in ED patients with chest pain.

OBJECTIVE: The objective of the study was to explore the association between physical fitness and the likelihood of acute coronary syndrome (ACS) in patients presenting to the emergency department (ED) with chest pain (CP). We hypothesized that the likelihood of ACS would be lower in physically fit patients and higher in patients with exercise-induced CP. METHODS: The study involved a prospective, descriptive cohort in an academic suburban ED. Subjects were ED patients with CP admitted for suspected ACS. Demographic and clinical data were collected by trained research assistants using standardized forms. Patients were surveyed on level of fitness and whether they had ever experienced anginal type symptoms during exercise. Acute coronary syndrome was considered present if the patient had electrocardiographic evidence of infarction or ischemia; elevated troponin I levels; greater than 70% stenosis of culprit coronary artery; or a positive nuclear, echocardiographic, or treadmill stress test result. Patients readmitted within 30 days for reinfarction, cardiogenic shock, or arrhythmias were also considered to have ACS. The association between physical fitness and ACS was determined using χ(2) tests and odds ratios (ORs). RESULTS: One hundred patients were enrolled. Mean age was 55.8 (±15.3) years; 36% were female; 85% were white. Thirteen (13%) patients had positive troponins, 22 of 36 catheterized patients had greater than 70% coronary artery stenosis, and 6 (6%) had abnormal stress test results. There were no deaths or reinfarctions within 30 days. The rate of ACS was similar in patients who were physically fit and those who were not (24% vs 37%; OR, 0.5 [95% confidence interval, 0.2-1.3]) and in patients who had experienced exercise-induced CP and those who had not (32% vs 29%; OR, 1.2 [95% confidence interval, 0.4-3.2]). Neither the frequency nor the intensity of exercise was associated with ACS. CONCLUSIONS: Physically fit patients with CP were as likely to have ACS as those not physically fit. A history of exercise-induced CP was not associated with an increased likelihood of ACS.

Primary closure of cutaneous abscesses: a systematic review.

BACKGROUND: Cutaneous abscesses have traditionally been treated with incision and drainage followed by secondary healing. Primary closure after incision and drainage is an alternative mode of therapy practiced in some parts of the world. The current study reviews the experience with primary closure of abscesses. METHODS: A systematic literature review was conducted using search terms abscess and primary closure. The databases searched included MEDLINE, PubMED, EMBASE, CINHAL, and the Cochrane Library between 1950 and 2009. The reference lists of the retrieved studies were also manually searched for additional studies. We performed a meta-analysis of all randomized clinical trials in which patients were randomized to either primary or secondary closure of incised and drained abscesses using Review Manager software. RESULTS: Of 33 articles retrieved, there were 7 randomized controlled trials in which 915 patients were randomized to primary (n = 455) or secondary (n = 460) closure. Many abscesses were located in the anogenital region and drained by surgeons. The time to healing after primary closure (7.8 days [95% confidence interval {CI}, 7.3-8.3]) was significantly shorter than that after secondary closure (15.0 days [95% CI, 14.3-15.7]; absolute difference, 7.3 days [95% CI, 6.9-7.6]). The rates of abscess recurrence after primary closure (7.6% [95% CI, 4.6-10.6]) were similar to those after secondary closure (11.1 days [95% CI, 7.5-14.7]; odds ratio, 0.66 [95% CI, 0.35-1.15]). CONCLUSIONS: Studies from 4 countries suggest that primary closure of incised and drained abscesses results in faster healing and similar low abscess recurrence rates than after secondary closure. These studies provide a foundation for which clinical trials can be conducted in the United States.

An Implementation Science Approach Improves Language Access in the Emergency Department.

BACKGROUND: The underuse of interpreters for limited English proficiency (LEP) patient encounters is pervasive, particularly in the emergency department (ED). OBJECTIVE: To measure the outcome of strategies to improve the use of interpreters by ED providers. METHODS: Pre- and post- intervention evaluation of the unmet need for language assistance (LA) in a public ED. Informed by the Behavior Change Wheel (BCW), strategies included: education, training, technology-based facilitators, local champions and environmental cues. RESULTS: Pre-intervention, of the 110 patient charts with interpreter requests, 17 (15.5%) had documentation of an interpreter-mediated encounter or were seen by a certified bilingual provider (unmet need = 84.5%). Post intervention, of the 159 patient charts with interpreter requests, 47 (29.6%) had documentation of an interpreter-mediated encounter or were seen by a certified bilingual provider (unmet need = 70.4%), difference + 0.14 (95% CI = 0.03-0.23). CONCLUSION: In this pilot study, we found a statistically significant increase in the met need for language assistance.

Anti-immigrant Rhetoric and the Experiences of Latino Immigrants in the Emergency Department.

INTRODUCTION: Anti-immigrant rhetoric and increased enforcement of immigration laws have induced worry and safety concerns among undocumented Latino immigrants (UDLI) and legal Latino residents/citizens (LLRC), with some delaying the time to care. In this study, we conducted a qualitative analysis of statements made by emergency department (ED) patients - a majority of whom were UDLI and LLRC - participating in a study to better understand their experiences and fears with regard to anti-immigrant rhetoric, immigration enforcement, and ED utilization. METHODS: We conducted a multi-site study, surveying patients in three California safety-net EDs serving large immigrant populations from June 2017-December 2018. Of 1684 patients approached, 1337 (79.4%) agreed to participate; when given the option to provide open-ended comments, 260 participants provided perspectives about their experiences during the years immediately following the 2016 United States presidential election. We analyzed these qualitative data using constructivist grounded theory. RESULTS: We analyzed comments from 260 individuals. Among ED patients who provided qualitative data, 59% were women and their median age was 45 years (Interquartile range 33-57 years). Undocumented Latino immigrants comprised 49%, 31% were LLRC, and 20% were non-Latino legal residents. As their primary language, 68% spoke Spanish. We identified six themes: fear as a barrier to care (especially for UDLI); the negative impact of fear on health and wellness (physical and mental health, delays in care); factors influencing fear (eg, media coverage); and future solutions, including the need for increased communication about rights. CONCLUSION: Anti-immigrant rhetoric during the 2016 US presidential campaign contributed to fear and safety concerns among UDLI and LLRC accessing healthcare. This is one of the few studies that captured firsthand experiences of UDLI in the ED. Our findings revealed fear-based barriers to accessing emergency care, protective and contributing factors to fear, and the negative impact of fear. There is a need for increased culturally informed patient communication about rights and resources, strategic media campaigns, and improved access to healthcare for undocumented individuals.

Provider and administrator-level perspectives on strategies to reduce fear and improve patient trust in the emergency department in times of heightened immigration enforcement.

STUDY OBJECTIVES: Heightened immigration enforcement may induce fear in undocumented patients when coming to the Emergency Department (ED) for care. Limited literature examining health system policies to reduce immigrant fear exists. In this multi-site qualitative study, we sought to assess provider and system-level policies on caring for undocumented patients in three California EDs. METHODS: We recruited 41 ED providers and administrators from three California EDs (in San Francisco, Oakland, and Sylmar) with large immigrant populations. Participants were recruited using a trusted gatekeeper and snowball sampling. We conducted semi-structured interviews and analyzed the transcripts using constructivist grounded theory. RESULTS: We interviewed 10 physicians, 11 nurses, 9 social workers, and 11 administrators, and identified 7 themes. Providers described existing policies and recent policy changes that facilitate access to care for undocumented patients. Providers reported that current training and communication around policies is limited, there are variations between who asks about and documents status, and there remains uncertainty around policy details, laws, and jurisdiction of staff. Providers also stated they are taking an active role in building safety and trust and see their role as supporting undocumented patients. CONCLUSIONS: This study introduces ED-level health system perspectives and recommendations for caring for undocumented patients. There is a need for active, multi-disciplinary ED policy training, clear policy details including the extent of providers' roles, protocols on the screening and documentation of status, and continual reassessment of our health systems to reduce fear and build safety and trust with our undocumented communities.