Development of a Pediatric Medical Home for Children Separated at the Border: A Partnership Between Every. Last. One. and the Children's Hospital of Los Angeles

Introduction: During 2019, we witnessed an unprecedented increase in children separated from their families at the Border. The American Academy of Pediatrics (AAP) published recommendations on the care of migrant children in detention, based on the principle that all children are deserving of access to quality care. The Children’s Hospital of Los Angeles (CHLA) Resident Continuity Clinic has partnered with local nonprofit organization Every. Last. One. (ELO), to create a medical home for children previously held in detention and reintegrated within the Los Angeles community.

Case Description: Our first patient through this partnership is a four-year-old girl who was held in an Office of Refugee Resettlement Shelter before being reunited with her mother in Los Angeles. After the child and parent did not show for their first appointment, established through ELO, parent was offered a same-day telehealth appointment with a resident and a Spanish interpreter. Discussion with the mother revealed fear of arriving at any clinic; questions about insurance; no transportation; and lack of understanding about the purpose of a well child visit. Interventions included connection to a bilingual coordinator who scheduled an in-person appointment for the next week, confirmed the child’s Medicaid plan, and worked with her insurance to arrange transportation. Patient and mother attended clinic the following week; Child warranted referral to subspecialty, mental health, dental, optometry, social work, and community support services. Use of frequent contact through telehealth and connection to staff who could navigate social barriers facilitated the establishment of a trusting patient-family-physician relationship. Of note, it was not until several visits later that her medical home team learned of a sibling who had been separated, detained, and in need of pediatric care.

Discussion: As the pediatric medical home team, it is our role to establish a secure relationship with this unique patient population and provide comprehensive medical care including addressing the trauma of separation. This is best achieved through use of a trauma-informed approach towards immigrant health, continuity with the medical and administrative team, flexibility with communication methods, and readily available, quality interpretation services. Comprehensive care includes addressing social determinants of health, barriers to accessing programs that support low-income children, access to education and mental health care, and coordination of health insurance.

Conclusion: The Resident Continuity Clinic at the Children’s Hospital of Los Angeles has partnered with a community organization, Every. Last. One, for the creation of a medical home for children previously held in detention and reintegrated within the Los Angeles community. Resources such as the AAP Immigrant Child Health and Trauma Informed Toolkits, and Physician’s for Human Rights Asylum Interviewing Training were used as frameworks for care. Lessons learned from each of these children can help pediatricians understand and address the complex health needs of this unique population.