PM3043: Scheduling Process Change Improves Access to Subspecialty Care for Unaccompanied Immigrant Children

Background: In recent years, the number of unaccompanied children (UCs) crossing the Southwest border of the US has greatly increased due to a variety of "push" and "pull" factors. After arrival, the vast majority of UCs are transferred to shelters run by organizations contracted with the Office of Refugee Resettlement (ORR). The average length of stay in these shelters is approximately one month due to the time needed to identify and vet an appropriate sponsor (typically, a parent or other close relative) for the UC in the US. While in the shelter, all UCs undergo an Initial Medical Examination within 2 business days of arrival, and it is generally required that any medical concerns identified be assessed prior to release from ORR custody. When subspecialty appointments are made more than one month from the date of the call, UCs that are otherwise ready for release to sponsors may be forced to remain in ORR custody awaiting medical clearance.

Methods: Regional shelters for UCs were informed to call the scheduling supervisors instead of the hospital's central scheduling department. Supervisors in the scheduling department were given an initial training on unaccompanied children, including guarantor and insurance payor as well as the rationale for creating a separate scheduling process. All supervisors tracked calls on a shared Excel spreadsheet. Contact information for the scheduling supervisors was distributed to all local shelters for UCs. Data from the Excel file from July 2018 to December 2021 were analyzed, with a particular focus on comparing the calendar years 2019 (pre-COVID) and 2021 (during COVID but after a 2020 federal policy restricting entry of UCs was reversed).

Results: Over 300 calls were fielded by the scheduling supervisors between July 2018 and December 2021. In 2019, the average length of time between date of call from the shelter staff and date of the appointment with the subspecialist was 14.63 days. In 2021, it was 7.78 days. The top ten specialties requested (respectively) were Cardiology, Neurology, Orthopedic Surgery, Dermatology, Otolaryngology, Gastroenterology, Gynecology, Urology, Ophthalmology, and General Surgery. Orthopedic Surgery had the shortest wait time between call and appointment (2.8 days) while Nephrology had the longest (25 days).

Conclusion: Improving access to care for immigrant child subpopulations can be achieved through process revision without the addition of expensive new resources. Public-private partnership -- e.g., between a private hospital and federal government-contracted shelter providers -- is critical to the success of projects involving UCs since shelter stays are typically followed by release into the community. The use of supervisors to schedule subspecialty appointments is an effective way to ensure that they are made in a timely fashion, thus preventing some delays in release of UCs to their community sponsors.