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CP21 - New Immigrant Case Management: Responding to the Southwest Border Crisis in a New Jersey FQHC

‐ Aug 18, 2021 11:20pm

CP21 - New Immigrant Case Management: Responding to the Southwest Border Crisis in a New Jersey FQHC

Poster Type: Innovation

Category: Expanding Access to Care and Other Services; Patient and Community Engagement; Public Health Crises; Social Determinants of Health; Workforce

Issue or Challenge: Zufall Health Center (ZHC) in New Jersey has seen hundreds of Central American child immigrants arrive over the past decade to our centers. These children are an extremely high-risk cohort, with particular need for assistance with school enrollment and linkage to legal services. While we have dedicated case management services for other high-risk populations (seniors, patients with mental illness or HIV), we have not had this available to new immigrant children and families. Using Americorps staff, Zufall has begun a program to identify new immigrant children within our practices and connect them with legal and social services.

Description of Innovation: In response to ongoing and increasing numbers of recently arrived migrant children, Zufall has begun a “New Patient Assistance” (NPA) program to provide case management to unaccompanied minors. Most significantly, the program has integrated a legal services linkage process where children are connected with pro bono or low-cost legal immigration services that can provide representation. There is no constitutional right to representation in immigration court, and it has been clearly shown that children who have representation are far more likely to have successful immigration cases. Many of these patients are not yet registered for public school, which is necessary for a successful asylum case, as well as for ongoing child development. NPA case managers assist with school registration, as well as with applications for Pandemic Rental Assistance; the Special Program for Women, Infants, and Children (WIC); and hospital charity care, by serving as translators and assisting with technology. Additionally, information is provided about local food pantries and other social services, and interested patients are referred to Zufall’s behavioral health services, as well as other medical and dental services as needed.

Impact or Result: Since the program was initiated in September 2020, NPA case managers have worked with 53 unaccompanied minors and 205 families. This has resulted in the connection of 59 of these patients with immigration attorneys and the registration of 8 children for public school. All patients have been provided information on local food pantries and social service programs. Legal services were reviewed with all families, and referral information was provided if a direct referral connection was not made. Given the current several-year wait time for resolution of typical immigration cases, it is difficult to assess the effect of this program on success within the court system. Regardless, the NPA referral process continues to wield considerable and measurable effect in breaking down barriers that our newly arrived immigrant children face. It is imperative that innovative and ground level programs continue to develop and evolve to meet the needs of this high-risk population.

Replicating this Innovation: This program is easily replicable and scalable within other health centers. FQHCs have a proven track record for case management, and understand the complex interplay of social factors that impact immigrant health. Furthermore, integrated and Trauma Informed Care that is offered at FQHCs make them an ideal location for this type of innovation. Medical-legal partnerships should be considered as standard enabling services offered at FQHCs. Americorps volunteers have been well placed to do this work in our organization.


Douglas Bishop, MD, Family Medicine Physician, Zufall Health Center