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Article of the Month

 , April 01, 2019

Advocacy for Patients with Vulnerable Legal Status: Piloting Immigration Legal Navigation in Primary Care

Sarah Kimball, MD; Mehar Maju; Lily Sonis, LCSW, MPH; Mara Eyllon, PhD

Dr. Kimball (Sarah.Kimball@bmc.org) is an assistant professor of medicine, Boston University School of Medicine. Ms. Maju (meharmaju@g.ucla.edu) is a second-year MPH student, Department of Community Health Sciences, at the UCLA Fielding School of Public Health. Ms. Sonis (lily.sonis@bmc.org) is medical case manager, Immigrant and Refugee Health Program, Boston Medical Center. Dr. Eyllon (meyllon@bu.edu) is postdoctoral researcher, Boston University School of Medicine.

The climate of fear created by anti-immigrant rhetoric and immigration policies that target vulnerable immigrant populations critically undermines the health and wellbeing of immigrant patients.1 Healthcare professionals have an ethical and professional obligation to provide care to anyone who needs it, regardless of their immigration status.2 In addition to providing high-quality health care for immigrants, developing interventions that promote their legal and human rights is a potent form of advocacy that is critical for ensuring the health and wellbeing of vulnerable immigrants. Though there is concern that immigrants will avoid the use of healthcare services due to fear of deportation, healthcare providers’ direct contact with immigrant populations puts them in a unique position to address immigration legal needs. Given this contact, healthcare providers can advocate for patients by providing resources and linking patients to legal counsel and immigration organizations.

The Medical-Legal Partnership (MLP) movement is an example of an evidenced-based intervention to address the unmet civil legal needs of patients. MLPs have demonstrated social and clinical impact by reducing patients’ stress and visits to the emergency room, while also improving housing outcomes and economic prospects in the communities they serve.3 Unfortunately, few MLPs provide immigration-specific legal services due to the complex and intensive nature of such services. Our experience working with patients in the Immigrant and Refugee Health Program (IRHP) at Boston Medical Center (BMC) has taught us that there is a tremendous need for immigration legal support in our patient population, and we have a potent opportunity to provide crucial support for immigrant patients when they come into clinic.

At the IRHP, we implemented a program in which an Immigration Legal Navigator (Navigator) was embedded into our clinic. The Navigator advocated for patients by referring them to community immigration legal resources and supporting them as they navigated the immigration legal process. The Navigator was an AmeriCorps member who received training from AmeriCorps on immigration-related issues and was employed by the clinic for the duration of a year. In the first year of this pilot, the immigration legal navigator worked with 271 patients, whose needs included asylum support (35%), documentation support (22.5%), green card support (21%), general immigration questions (10%), citizenship support (5.2%), family reunification support (4%), medical deferred action support (1.5%), and deportation defense (0.7%).4

To better understand the barriers immigrant patients face, and the efficacy of the program at successfully advocating for immigrant patients, we used thematic analysis to analyze the Navigator’s monthly reflections detailing her greatest successes and challenges with immigrant patients. Here, we focus on three themes identified that highlight the importance of the Navigator as an advocate for patients with vulnerable immigration status:

Immigration Status is a Social Determinant of Health: Increasingly, immigration status is recognized as an independent social determinant of health, driving health disparities through structural inequalities.5 Many of the Navigator’s cases demonstrated how immigration challenges complicate and are inextricably linked to health outcomes. The combination of a serious illness and immigration vulnerability can be difficult for patients to overcome without assistance. As the Navigator described in a journal entry:

“I met with a husband and wife who both did not speak English. The wife had cancer and was receiving treatment at BMC, but had overstayed her visa. The husband needed a green card renewal…. I contacted [an immigration legal organization], but the patients needed an in-person interpreter to help fill out the forms, which was an added challenge.”

Additionally, the navigator described the financial burden associated with acquiring legal representation for patients:

“Without [my support], I think that this patient would have gone with a private attorney for her legal needs. She has two daughters who are in school, and is essentially living paycheck to paycheck. The added expense of a private attorney would have been an enormous burden on this single mother.”

Patient emotional support and empowerment: Many patients reported that their immigration challenges were overwhelming and isolating. However, receiving support within the same environment where they were seeking clinical care mitigated some of their emotional distress. For instance, the Navigator described:

“I was introduced to a patient this month who was feeling incredibly overwhelmed. She had a complicated history and wanted help connecting with a lawyer. When she first came into my office, she told me that she had nowhere else to turn and felt completely alone. I was able to find this patient legal representation, which in turn helped her find some peace of mind.”

Many patients with legal vulnerabilities have to navigate a complex legal system that presents challenging demands, such as acquiring the right paperwork despite language barriers. This is complicated by imminent deadlines for paperwork, which if not met, could lead to deportation. Through the Navigator, patients were supported while learning how to navigate the complex immigration legal system, which in turn led to a higher sense of self-empowerment among patients. As the Navigator described:

“I think this patient would not have been able to find legal resources on her own. She, like many of the other patients who I have been in contact with, had trouble advocating for herself. In the time that I have known her, she has become increasingly independent, and I feel it is because she knows she is not alone in the process.”

Interprofessional collaboration to secure legal representation: The Navigator frequently noted how crucial interprofessional collaboration was for resolving cases. By serving as an intermediary between clinicians and attorneys, she was able to overcome many of the barriers that typically make this type of collaboration difficult. For instance, she said:

“This month, a patient came to see me who needed an urgent letter from her primary care provider. She was put into deportation proceedings, and was given an extremely short timeline to get this treatment letter. I was able to connect with the patient’s lawyer and PCP, and provide the PCP with guidelines for writing the letter... I think it was really helpful having this experience and also the time to coordinate all the different pieces on an expedited timeline.”

This collaboration was bidirectional, and allowing legal collaborators to also get support with medical concerns.

“I saw a patient who was an asylum seeker... The patient seemed very symptomatic. I had referred this patient to [a legal collaborator], and I actually got a call from [them] about this patient saying they were worried about him and wanted to schedule him for an appointment. She wanted to know if I would be able to accompany him to his next appointment… The fact that I had formed a working relationship with [this organization] meant that she was able to reach out to me directly about the patients I referred to her.”

The medical profession has a deep history of building interventions to combat the effects of the social inequalities that increase health disparities. Our pilot project suggests that while many immigrant patients face challenges and experience distress regarding their immigration statuses, advocacy and helping patients connect with resources can be empowering. Given the effects of current political climate, it is incumbent on all of those who are care for immigrant patients to find ways to mitigate the harm that has negatively impacted many of our patients’ physical and mental health. We believe that interventions such as ours that try to ameliorate this disparity are an important advocacy tool for clinicians and health systems.

References
Katz MH, Chokshi DA. The “public charge” proposal and public health: Implications for patients and clinicians. JAMA. 2018 Nov 27;320(20):2075-2076. doi: 10.1001/jama.2018.16391.
AMA policies and code of medical ethics’ opinions related to health care for patients who are immigrants, refugees, or asylees. AMA J Ethics. 2019 Jan 1;21(1):E73-77. doi: 10.1001/amajethics.2019.73.
Pettignano R, Bliss L, Caley S. The health law partnership: A medical-legal partnership strategically designed to provide a coordinated approach to public health legal services, education, advocacy, evaluation, research, and scholarship. J Legal Med. 2014;35(1):57-79. doi: 10.1080/01947648.2014.884892.
Kimball S, Singh N, Maju M, et al. (in press). Embedding an immigration legal navigator in a primary care clinic. Ann Fam Med. 2019;17:177. https://doi.org/10.1370/afm.2360.
Castañeda H, Holmes SM, Madrigal DS, et al. Immigration as a social determinant of health. Annu Rev Public Health. 36(1), 375–392.



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