Land Acknowledgement

Our chapter territory spans from the northern border of California to the southern border of Monterey, Kings, Tulare and Inyo counties. This land was once the home for Native Americans from over 40 different tribes. Native Americans from these territories still live in California and have strong, vibrant communities and cultures. We’d like to acknowledge those tribes and respect the history of the land that we now inhabit.

https://native-land.ca/

Agenda

7:00: Introductions

7:10: Dr. Lisa Gantz - Clinical Recommendations Review

7:30: Introduction to Panel

7:40: Panel (5-10 minutes each)

Karen Gersten-Rothenberg, NP

Associate Medical Director of School Based Health Centers at La Clinica de La Raza in Oakland where they have serve many unaccompanied and immigrant children

Dr. John Harlow

Founder of La Linterna at AltaMed Health Services in Los Angeles where they provide holistic care for refugee and immigrant families

Dr. Gaspar Rivera

Medical Director of School Based Health Centers at Benioff Children's Hospitals Oakland where they have a close relationship with a newcomer high school

Dr. Eleanor Chung

Director and Founder of the Bridges Clinic at SF General Hospital where family navigators are integrated into the model of care for newcomer children and families

8:15: Discussion/Q&A

8:30: Close

Meet our Speakers

From Left to Right:

Lisa Gantz, MD, FAAP - Associate Professor of Pediatrics at UCSF, Primary and Urgent Care at SF General Hospital Children’s Health Center (CHC), Associate Medical Director of Specialty Care at CHC, Co-Medical Director and Founder of Bridges Clinic.

Karen Gersten-Rothenberg, MSN, FNP - Associate Medical Director of School Based Health Centers at La Clinica de La Raza in Oakland where they have serve many unaccompanied and immigrant children

John Harlow, MD - Founder of La Linterna at AltaMed Health Services in Los Angeles where they provide holistic care for refugee and immigrant families

Gaspar Rivera, MD, MPH, FAAP - Medical Director of School Based Health Centers at Benioff Children's Hospitals Oakland where they have a close relationship with a newcomer high school

Eleanor Chung, MD - Director and Founder of the Bridges Clinic at SF General Hospital

Clinical Care for Immigrant Children: A Primer for Pediatricians���March 23^rd, 2022��

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Lisa Gantz, MD

UCLA Pritzker Center Child Health & Wellbeing Fellow 2020-2022��

Sural Shah, MD MPH�Chief, Division of Primary Care, Department of Medicine, OVMC-UCLA�Director, Olive View Human Rights Clinic

Disclosures

No conflicts of interest to disclose.

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By the end of this lecture, participants will be able to:

• Briefly review the typical experiences of unaccompanied minors (UMs), including predeparture, journey to the US, and post-arrival—and how these experiences impact screening and treatment in clinical practice

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• Name the key components for clinical care of unaccompanied immigrant children

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• Locate local, regional, and national resources to assist in the care of immigrant children

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What this talk will NOT cover…

• Immigration reform
• History of immigration policy
• Family separation
• Laws and policies impacting families / immigrant youth who arrive with parents or guardians
• Details of enforcement policies and options for legal relief
• Care of refugee children and families

​

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“Children do not immigrate, they flee. ”

Fernando Stein MD, FAAP

Source: https://unchrwashington.org/children

Definition

Unaccompanied Alien Child (UAC): a technical term defined by law as “a child who

(A) has no lawful immigration stat­us in the United States;

(B) has not attained 18 years of age

(C) with respect to whom—

(i) there is no parent or legal guardian in the United States;

or

(ii) no parent or legal guardian in the United States is available to provide care and physical custody.

Accompanied children: detained with parent or legal guardian

- DHS refers to as “family units”

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Non-dehumanizing and non-othering terms:

• Unaccompanied minors (UMs)
• Unaccompanied immigrant minors
• Unaccompanied immigrant child/children
• Unaccompanied child/children

Source: https://www.hhs.gov/sites/default/files/Unaccompanied-Alien-Children-Program-Fact-Sheet.pdf

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Source: http://refugees.org/explore-the-issues/unaccompanied-migrating-children-facts/

Learning Point One: �Unaccompanied minors are at risk for trauma at all points in their migration process

Adapted from: Kirmayer LJ, Narasiah L, Munoz M, et al. Common mental health problems in immigrants and refugees: general approach in primary care. CMAJ. 2011;183(12):E959-E967.

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Apprehension and Processing Experiences

(Post-migration)

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No (from Mexico/Canada and can be safely returned)

Unaccompanied minor placed in shelter or other facility operated by Office of Refugee Resettlement (ORR) (including EIS sites)

Released to care of community sponsors for the duration of their immigration case

Released into the community awaiting immigration hearing

Placed in Immigration and Custom Enforcement (ICE) family residential centers

Repatriated back to home country under expedited removal procedures

Detained in CBP Processing center

Adult accompanying child verified to be legal guardian

No

OR

OR

Yes

Government Agency

• US Department of Homeland Security (DHS)
• US Department of Health and Human Services (HHS)

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Population

• Family Units
• Unaccompanied Minors (Mexico/Canada)
• Unaccompanied Minors (non-contiguous countries)

​

Learning Point Two: �Trauma-informed care is crucial when interacting with unaccompanied minors

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Key Resource: AAP Trauma Toolbox

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https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Trauma-Guide.aspx#trauma

Key Resource: RWJ Clinical Scholars UM Toolkit (Feb 2021)

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Source: Baez, JC, Swamy P, Gutierrez A, Garcia N, & Misra SM. (2021). Caring for former unaccompanied immigrant minors: a culturally relevant and trauma responsive toolkit for providers. Clinical Scholars. Https://www.bbhouston.org/

https://www.bbhouston.org/toolkit

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Source:Https://www.bbhouston.org/

Learning Point Three: �The initial medical visit with a UM is a regular WCC (plus a few special considerations)

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Health Considerations in Immigrant Children

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What type of medical and mental health care do children receive while in ORR custody?

• Initial Medical Exam must be conducted within 2 business days
• Psychological evaluation is completed within 24 hours
• Emergency, subspecialty, and inpatient care as needed
• ORR has medical decision-making authority
• Insurance provided

What is done during the Initial Medical Exam (IME) at ORR?

• Vital signs, hearing, vision
• History: Concerns, PMH, PSH, Family History, Reproductive History, Psychosocial, Physical Abuse, Sexual Abuse (SA), Substance Use, ROS
• Physical Exam: include genitalia
• Labs:
• Covid testing
• TB testing for everyone (IGRA or PPD) + CXR if ≥15 years of age
• flu if fever + cough
• STI/HIV if ≥13 years or sexual activity/SA
• pregnancy if ≥10 years
• lead if 6 months to 6 years
• Hep B/GC/Chlam/Syphilis if sexual activity/SA
• Hep B/C if IVDU
• As needed: vaccinations, follow-up, referrals, medications

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Key Resource: AAP Immigrant Youth Toolkit (National)

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https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Immigrant-Child-Health-Toolkit/Pages/Immigrant-Child-Health-Toolkit.aspx

Key Resource: AAP CA1 Clinical Guide for 1^st visit

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https://aapca1.org/immigrant-child-clinical-recommendations/

Key Resource: AAP CA1 Clinical Guide for 1^st visit

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I think I may be interacting with a patient who meets definition of UM- how do I know for sure?

How much detail do I need about migration history?

• Knowing “for sure” or knowing “the full story” is not necessary- but identifying and responding to social, legal, mental health needs IS necessary
• Usually not appropriate to ask directly about immigration status
• Conduct social history as you normally would, but pay close attention for clues
• Ask open-ended follow-up questions, ask permission and allow them to choose to answer a question or not
• DO NOT DOCUMENT IMMIGRATION STATUS IN MEDICAL RECORD

How do I ask about immigration history?

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Source: AAP Trauma Toolkit- https://www.aap.org/en-us/Documents/ttb_medicalhomeapproach.pdf

Key Resource: AAP CA1 Clinical Guide for 1^st visit

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Treatments and Referrals

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How do I get prior medical records from when child was in ORR custody?

Source: https://www.acf.hhs.gov/orr/resource/unaccompanied-childrens-services

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Benefits and Access for UMs

​

Sources: http://calfresh.guide/immigrant-eligibility-for-calfresh-benefits/#qualified

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Immigrant-Child-Health-Toolkit/Pages/Access-to-Health-Care-and-Public-Benefits.aspx

Key Resources: Legal Aid

UMs are not guaranteed legal representation

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Key Local Resource: AAP CA2 Los Angeles County Immigrant Youth Toolkit

https://aapca2.org/toolkit/

Acknowledgements

• Sural Shah, MD MPH
• Raul J Gutierrez, MD MPH
• Karla Fredricks, MD, MPH
• Anisa Ibrahim, MD
• Eric Russell, MD
• Elizabeth Dawson-Hahn, MD, MPH
• Brian Lonquich, MD
• Rebecca Virata, MD
• Kaitlyn Hardin, MD
• UCLA Firm A Advocacy Council- Grace Kim, MD, Olivia Wu, Allison Farfel, Xavier Gaeta, Grace Kim,, Malina Lim, Gurpreet Seehra, Myriam Shehata (LAHRI), Lizzie Wang

​

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AAP Immigrant Child Health Toolkit (National)

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AAP Trauma Toolbox for Primary Care

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UM Bridge Unaccompanied Minors Toolkit

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AAP CA2 LA County Immigrant Youth toolkit (local)

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Questions?

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• Lisa Gantz- lgantz@dhs.lacounty.gov
• Sural Shah- sshah9@dhs.lacounty.gov

​

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AAPCA1 Resource:

Immigrant Child Clinical Recommendations

View at:

https://aapca1.org/immigrant-child-clinical-recommendations/

Downloadable at:

https://aapca1.org/combating-public-charge-rule-misinformation/

Meet our Panelist

From Left to Right:

​

Karen Gersten-Rothenberg, MSN, FNP - Associate Medical Director of School Based Health Centers at La Clinica de La Raza in Oakland where they have serve many unaccompanied and immigrant children

John Harlow, MD - Founder of La Linterna at AltaMed Health Services in Los Angeles where they provide holistic care for refugee and immigrant families

Gaspar Rivera, MD, MPH, FAAP - Medical Director of School Based Health Centers at Benioff Children's Hospitals Oakland where they have a close relationship with a newcomer high school

Eleanor Chung, MD - Director and Founder of the Bridges Clinic at SF General Hospital

�School Based Health Centers at Benioff Children's Hospitals Oakland

Clinical Recommendations and Models of Care for Newcomer Children

Gaspar Rivera, MD, MPH

Outline

• SBHC Key Components
• Leadership and Stakeholders
• Success Stories

Key Components for Newcomers at our SBHC

• Location
• Mental Health Services
• Health Education/Group Medical Visits
• FIND Navigation (food insecurity support, navigating health care, etc…)
• Social Work Support
• Including PEARLS screening and support

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Location

• Castlemont High School
• Public High school with large newcomer population (52% of students are English Language Learners)
• 67% Latino, 27% Black students
• 91% of students are economically disadvantaged
• Rudsdale Continuation High School
• Continuation school just for newcomer immigrant students > 16 yrs or older, and who need to work or care for their families.
• LPS Oakland
• Public charter high school
• 30% English Language Learners

Location

• Convenient location for students to complete medical requirements needed to continue/start school
• Reduces barriers such as transportation
• Presence of mental health, health education and Social Work team in schools leads to referrals to clinic and identification of patient needs
• Health Education to students and parents possible (i.e. back to school night, assemblies, group medical visits)

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Mental Health Services

• Structure: Behavioral Health Director, Multiple therapist (most Spanish speaking), intermittent crisis support for school
• Referrals can come from school or clinic
• SBHC Psychiatrist available but referral must come from therapist (due to limited capacity)
• Social Work team can provide brief therapy

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Health Education/Group Medical Visits

• Health Education team (grant funded) provides sexual health education classes to subset of students
• Group Medical visits conducted as part of this sexual health education
• Youth Leadership Group
• Not targeted specifically for newcomer patients but newcomer patients benefit
• Helps with productivity pressures from institution
• One goal is to improve health literacy

FIND Navigation

• Family Information & Navigation Desk (FIND)
• Social determinants of health (SDoH) approach to medical care
• Help with food insecurity resources, transportation, health navigation, community resources, etc..
• Position not always filled

Social Work

• 1 full time SW, mostly grant funded for now
• Spanish speaking
• PEARLS screening and support
• Brief therapy, crisis support in clinic
• In school support intermittently (i.e. grief support recently after death of student)

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Leadership and Stakeholders

• We have overwhelming support from FQHC leadership
• But productivity can be low
• Ongoing advocacy needed
• For example, our clinic hours were among the first cut during the pandemic and the last to be restored
• Ongoing search for funding
• Continued relationship with students, OUSD and Castlemont Leadership

Shared Story

• “What do you think of the school?”
• FIND navigation looking for undocumented scholarships
• Crisis support in clinic for experienced trauma
• Countless vaccines administered
• PEARLS implementation – still learning

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March 23, 2022

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Eleanor Chung, MD

Co-Medical Director of Bridges Clinic with Dr. J. Raul Gutierrez

Children’s Health Center, San Francisco General Hospital

Implementation of Clinics for Newcomer Children:

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Bridges Clinic, SFGH

Bridges Clinic

MISSION

CHC Bridges Clinic aims to provide team-based, culturally-responsive care for newcomer children & their families, to support health and resilience rooted in equity and the community.

�VISION

Every individual has the right to pursue health and well-being regardless of where they are from, or where they live.

Family Navigators

And Community Health Workers – interns from CCSF CHW certificate program

Jocelyn

Bonilla

Bridges Clinic at Children’s Health Center

• CHC is located within San Francisco General Hospital, and serves as one of the largest children’s clinics in the Bay area.
• CHC ~10,000 outpatient visits per year in primary care
• 20+ MDs/NPs, residents
• Behavioral Health team (incl Healthy Steps)
• UCSF/SFGH Health Advocates
• Urgent Care
• Pediatric Specialty clinics – cardiology, neurology, asthma, derm, Healthy Lifestyles/nutrition.

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Bridges Clinic – co-located within CHC: Started in October 2017

• 300+ referrals received to date
• <5 from Nepal, Vietnam, Yemen, Ecuador, Nicaragua
• Mexico, El Salvador, Guatemala, Honduras

6M BRIDGES CLINIC: Oct 2017 – Jan 2022

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300+ referrals received since 2017

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From 5-6 per month, to 40-50 per month

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98% from Mexico, El Salvador, Guatemala, Honduras

<2% from Nepal, Vietnam, Yemen, Ecuador, Nicaragua

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<6yr

6-12yr

12-18yr

>18yr

6M Bridges: Tailored Primary Care

6M Bridges: Key Partners

Does NOT need Medi-cal

SFUSD

Newcomer student

= Navigation

SCHOOL ENROLLMENT

• Quantiferon results
• Vaccines (dependent on age)
• Tdap/VZV
• Pediarix, MMRV

= Priority

immediate mental or physical health, housing, and/or food needs

PATIENT

• MyChart
• Call Medical records
• Request from provider

PROVIDER

• Fax
• Email
• Print out for patient

Sharing PPI

(results, records)

HIPAA, ROI

SFUSD

• CAIR
• Request from provider
• Request from patient

Referral to CHC Bridges Clinic

Internal – within SFHN

Pediatric Urgent/primary Care

ED

Nursery

Women's Health (5M)

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External – community, outside SFHN

Community (qualtrics form)

SFUSD (3 schools)

CBOs

Other FQHCs

Referral

Pre-Visit / Intake

Clinic Visit

Follow-up

Family Navigation

Process

Secure shared folder for Bridges and key partners

Smart phrases

Charting / care coordination, example

Acculturation Difficulty (Z60.3)

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• Updated 02/18/22: 

[x ] Health insurance 

[x ] Housing & utilities - working with Compass, homeless but has temp housing, stable 

[ ] Employment – referred by FN

[x ] Transportation (MUNI lifeline) - gave tokens 

[/ ] Food - has resources but could use more support; provided 6M pantry box and Bridges GC (gift card). Forgot to ask about WIC. 

[/ ] Legal resources - working with LRCL but sib's case still pending 

[- ] Mental health - no acute needs at this time 

[x ] School/daycare 

[- ] ESL 

[ ] Dental - needs referral 

[/ ] SF ID – has appt, needs proof of res letter

History and examination, immigration (Z02.2)

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Baseline screening labs WNL

QFT NEG (2/6/22)

No IZ rec – start catch-up schedule

Pitfalls/hurdles

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• Incorrect address / ph#
• Frequent relocation
• Incorrect name / DOB
• Literacy (illiterate, dialect, other)
• No email account
• Mixed family units
• Special needs – misdiagnosis
• Isolation

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Can impact:

• Medi-Cal
• Picking up meds
• SF ID
• Patient EHR
• Receiving Notice to Appear (for immigration court, other)
• SFUSD communication
• Speciality communication
• Disjointed primary care (different PCPs, messaging)
• Mental health

6M Bridges: Only possible with community partners

SF Coalition of Asylee, Immigrant, and Refugee Services

• Asylee orientation
• Civil surgeon examinations
• SFDPH Newcomer’s Health Clinic

Looking forward

Take 2 Minutes to Let Us Know if This Session was Helpful!

https://www.surveymonkey.com/r/clinicrecc4newcomerchildeval

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Upcoming Events https://aapca1.org/events/

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April 13 - Enhancing Adolescent Health & Immunization Services AAP Webinar

April 20 - Mental Health Chat w/ CAPP

May 7 - Annual Spring CME Conference in Fairfield

May 11 - Mental Health with CAPP

June 8 - HP 2020 Medical Legal Partnerships

June 22 - Enhancing Adolescent Health & Immunization Services AAP Webinar