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A theoretical framework and mixed-methods investigation of document status as a social determinant of emergency department utilization…

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Content A THEORETICAL FRAMEWORK AND MIXED-METHODS INVESTIGATION OF DOCUMENTATION
STATUS AS A SOCIAL DETERMINANT OF EMERGENCY DEPARTMENT UTILIZATION AT THE
LARGEST URBAN SAFETY-NET HOSPITAL IN LOS ANGELES, CALIFORNIA
by
Cynthia Nicole Ramirez
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
PREVENTIVE MEDICINE (HEALTH BEHAVIOR)
December 2023
Copyright 2023 Cynthia Nicole Ramirez

ii
Epigraph
“Quisieron enterrarnos, pero se les olvido que somos semillas \ They tried to bury us, they
didn’t know we were seeds.”
—Unknown.

iii
Dedication
To Mama, Papa, and Lan. Los quiero mucho.

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Acknowledgments
I want to thank the various agencies, institutes, and individuals that made this dissertation
possible, including the AHRQ R36 dissertation award and KSOM Department of Emergency
Medicine Seed Grant for providing the financial support and protected time needed to
complete this work.
I also need to thank my dissertation committee members for their countless hours of support
and encouragement: Dr. Unger, Dr. Burner, Dr. Farias, Dr. Bluthenthal, Dr. Kim, and Dr. Javier.
It’s been a privilege to work with and learn from all of you. I’d also like to thank my honorary
committee members, Dr. Axeen, Dr. Pickering, and Dr. Schneberk. Thank you for your
substantial contribution to this work.
I’d also like to acknowledge the assistances of various undergraduate and graduate students in
collecting, transcribing, translating, and analyzing the interviews discussed in this dissertation,
including Vanessa, Rodrigo, Michella, Citlally, and Carol. It was an honor and privilege to work
with each of you. I also want to thank the providers and staff at LA General Medical Center for
welcoming me into their workspace and supporting this research.
To my parents, Ana and Jose, and brother, Julian, thank you for believing in me, creating a
supportive learning environment, and instilling in me the importance of honoring, celebrating,
and advocating for the communities that we love. Thank you for supporting me every step of
the way—I couldn’t have done it without you. Also, shoutout to Milo for his countless hours of
emotional support—*Drake voice*—started from the kennel now we here.
Thank you to my peers and friends for making sure I got all the pep talks, laughs, advice, and
dinner dates I needed to get through this: Ingrid, Jen, Maria, Brooke, Tobin, Esthelle, Raymond,
Christine, Sam, Beatrice and the Writing Warriors, and Nia, to name a few.
I want to thank Dr. Galarza, Dr. McMullin, Dr. Lai, and Dr. Schiewe for helping me to prioritize
my physical, emotional, and mental health throughout this process.
Finally, I want to thank the patients at LA General Medical Center Emergency Department for
trusting me with their stories and lived experiences. None of this would have been possible
without you.

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Table of Contents
Epigraph ...........................................................................................................................................ii
Dedication.......................................................................................................................................iii
Acknowledgments...........................................................................................................................iv
List of Tables .................................................................................................................................viii
List of Figures..................................................................................................................................ix
Abstract............................................................................................................................................x
Chapter 1: Introduction .................................................................................................................. 1
A Brief Overview of Immigration in the U.S................................................................................ 1
A Brief Overview of Undocumented Immigrants Residing in the U.S. ....................................... 2
Immigration Policies in the Context of Health and Health Access ............................................. 5
The Exclusion of Undocumented Immigrants from the Affordable Care Act............................. 9
Undocumented Immigrants and Safety-Net Services .............................................................. 11
Safety-Net Literature Lacks Representation of Undocumented Immigrants........................... 13
The Relationship between Health Care Access and Ambulatory Care Sensitive Conditions ... 15
Overview and Triangulation of Studies..................................................................................... 17
Implications of Proposed Studies ............................................................................................. 19
Chapter 2: A Grounded Theory Approach to Understanding the Emergency Care-Seeking
Processes of Documented and Undocumented Safety-Net Patients at an Urban Safety-Net
Hospital in Los Angeles: A Qualitative Analysis............................................................................ 20
Study Objective......................................................................................................................... 20
Background ............................................................................................................................... 20
Methods.................................................................................................................................... 21
Results....................................................................................................................................... 21
Conclusions............................................................................................................................... 22
Introduction .............................................................................................................................. 23
Goals of This Investigation........................................................................................................ 27
Methods.................................................................................................................................... 27
Data Analysis............................................................................................................................. 32

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Results....................................................................................................................................... 33
Discussion.................................................................................................................................. 50
Limitations................................................................................................................................. 53
Summary ................................................................................................................................... 54
Conflicts of Interest................................................................................................................... 55
Funding ..................................................................................................................................... 55
Acknowledgments..................................................................................................................... 55
Chapter 3: The Association between Patients’ Documentation Status and Emergency
Department Visit for an Ambulatory Care Sensitive Condition (ACSC) in an Urban
Safety-Net Hospital in Los Angeles: A Cross-Sectional Study ....................................................... 56
Study Objective......................................................................................................................... 56
Background ............................................................................................................................... 56
Methods.................................................................................................................................... 56
Results....................................................................................................................................... 57
Conclusions............................................................................................................................... 57
Introduction .............................................................................................................................. 58
Goals of This Investigation........................................................................................................ 59
Methods.................................................................................................................................... 59
Data Analysis............................................................................................................................. 69
Results....................................................................................................................................... 70
Sample Characteristics by Documentation Status Classification.............................................. 71
Discussion.................................................................................................................................. 81
Limitations................................................................................................................................. 83
Summary ................................................................................................................................... 85
Conflicts of Interest................................................................................................................... 85
Funding ..................................................................................................................................... 85
Acknowledgments..................................................................................................................... 85
Chapter 4: Contextualizing Undocumented Safety-Net Patients’ Emergency Department
Visit for an Ambulatory Care Sensitive Condition (ACSC): A Qualitative Secondary Analysis...... 86
Study Objective......................................................................................................................... 86
Background ............................................................................................................................... 86

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Methods.................................................................................................................................... 86
Results....................................................................................................................................... 87
Conclusions............................................................................................................................... 87
Introduction .............................................................................................................................. 88
Goal of This Investigation.......................................................................................................... 91
Methods.................................................................................................................................... 91
Data Collection.......................................................................................................................... 95
Data Analysis............................................................................................................................. 95
Results....................................................................................................................................... 96
Discussion................................................................................................................................ 103
Limitations............................................................................................................................... 107
Conflicts of Interest................................................................................................................. 108
Funding ................................................................................................................................... 108
Chapter 5: Conclusions ............................................................................................................... 109
Summary of Findings............................................................................................................... 109
Recommendations.................................................................................................................. 111
References .................................................................................................................................. 116

viii
List of Tables
Table 1. Sample Approach Script.................................................................................................. 30
Table 2. Sample Interview Questions and Probes........................................................................ 31
Table 3. Sample Documentation-Status Questions...................................................................... 32
Table 4. Participant Characteristics .............................................................................................. 35
Table 5. Themes and Supportive Quotes of General Influences of ED Care-Seeking .................. 39
Table 6. Themes and Supportive Quotes of Undocumented Participants’ Unique
Safety-Net ED Care-Seeking Processes............................................................................ 46
Table 7. Insurance Names, Descriptions, and Codes Used to Create Seven-Category
Insurance Variable........................................................................................................... 61
Table 8. AHRQ’s List of ACSCs and Their Corresponding ICD-10-CM Diagnosis Codes................ 65
Table 9. Conditions, Weights, and Corresponding Diagnosis Codes Used to Create
Modified CCI .................................................................................................................... 67
Table 10. Sample Characteristics by Documentation Status Classification.................................. 72
Table 11. ASCS Frequencies and Composites............................................................................... 74
Table 12. Sample Characteristics by Age Category....................................................................... 77
Table 13. Multivariate Logistic Regression Results on the Association of Documentation
Status with ED Visit for ACSCs by Age ............................................................................. 79
Table 14. Sample Interview Questions and Probes...................................................................... 94
Table 15. Participant Characteristics by ACSC Status................................................................... 97
Table 16. Themes and Supportive Quotes among Undocumented Safety-Net Patients
with an ACSC.................................................................................................................... 98
Table 17. Themes and Supportive Quotes Pertaining to Referrals Theme among
Undocumented Safety-Net Participants Seen for Other Conditions............................ 100
Table 18. Supportive Quotes Pertaining to Secondary Citizens Theme among
Undocumented Participants Seen for Other Conditions .............................................. 101

ix
List of Figures
Figure 1. Conceptual Model of Dissertation Studies Using a Sequential Mixed-Methods
Design............................................................................................................................. 18
Figure 2. Strobe Diagram of Study Recruitment Efforts............................................................... 34
Figure 3. Theory of the Safety-Net Emergency-Care-Seeking Process as Described by
Documented and Undocumented Participants............................................................. 50
Figure 4. Categorization of U.S.-Born Patients............................................................................. 63
Figure 5. Categorization of Likely-Documented Patients Using Country of Birth,
Social Security Number, and Insurance Type Data........................................................ 64
Figure 6. Categorization of Likely-Undocumented Patients Using Country of Birth,
Social Security Number, and Insurance Type Data........................................................ 64
Figure 7. Inclusion Criteria and Development of Our Analytic Sample ........................................ 71
Figure 8. Revised Theoretical Framework of Emergency Care-Seeking among
Undocumented Safety-Net Patients with an ACSC and Those Seen for
Other Conditions.......................................................................................................... 103

x
Abstract
In 2018, the United States Department of Homeland Security estimated that
approximately 11.4 million undocumented immigrants were residing in the U.S. (Baker, 2021).
Though limited research among the population exists, studies conducted to date have shown
that undocumented immigrants are more likely to be low income and uninsured, as well as lack
a usual source of care, use fewer preventive health services, and report poor health outcomes
as compared to their U.S.-born and documented counterparts (Atkins et al., 2017; Atkins et al.,
2018; Balakrishnan & Jordan, 2019; Cervantes et al., 2021; Cha et al., 2019; Guerrero et al.,
2016; Torres & Waldinger, 2015). Due in large part to exclusion from public benefits, including
the Affordable Care Act (ACA), undocumented immigrants’ ability to obtain comprehensive
health insurance remains extremely limited. Barriers to care coverage leave many
undocumented immigrants uninsured and dependent on safety-net health systems, particularly
emergency departments (ED), when experiencing health care needs. Despite their unique care
needs, little is known about undocumented patients’ ED care-seeking processes in the safetynet setting, including how and when patients decide when and where to seek safety-net ED
care versus ambulatory care such as primary and specialty care. Furthermore, little is known
about the association between documentation status and avoidable ED utilization for
ambulatory care sensitive conditions (ACSCs). To address the knowledge gap, this dissertation
conducts a comprehensive, mixed-methods investigation of documentation status as a social
determinant of safety-net ED utilization at the largest public hospital in Los Angeles, California.
Using a sequential design, each study informs and builds upon the others. Qualitative findings
from study 1 inform the quantitative research question investigated in study 2, and results from

xi
studies 1 and 2 inform and contextualize the qualitative secondary analysis performed in study
3. Using a grounded theory approach, the first study develops a theoretical framework of
safety-net ED care-seeking processes described by safety-net patients during semistructured
interviews (n=25) and highlights distinct ED care-seeking processes described by undocumented
patients. The second study uses multivariate logistic regression to investigate the association
between documentation status and ED visit for an ACSC in a sample of n=129,834 safety-net ED
patients at the largest public hospital in Los Angeles between 2016 and 2019. Results indicated
that undocumented immigrants aged 26 to 64 had higher odds of ED utilization for an ACSC
compared to U.S.-born individuals. Study 3 integrated results from studies 1 and 2 to inform a
qualitative secondary analysis of the original theoretical framework. Results showed that
undocumented patients whose ED visit pertained to an ACSC (n=5) described safety-net ED
care-seeking processes distinct from those whose were seen for other conditions. The
dissertation concludes by providing recommendations and future directions to address gaps in
the literature and reduce existing inequities in ambulatory care access experienced by
undocumented immigrants residing in Los Angeles.

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Chapter 1: Introduction
A Brief Overview of Immigration in the U.S.
The United States has the largest foreign-born population in the world, with more than
40 million immigrants (approximately 14% of the population) residing in the country as of 2018
(Budiman, 2020). The term “immigrant” is used to describe a person who lives in a country
where they were not born and who has the intention to stay permanently. In the U.S., some
foreign-born persons who intend to remain in the country only temporarily are considered
“nonimmigrants,” including students and temporary workers (Bolter, 2019). The U.S.
Department of Homeland Security (USDHS) recognizes two broad categories of immigrants
residing in the U.S.: 1) legal residents, including “naturalized citizens, persons granted lawful
permanent residence, persons granted asylum, persons admitted as refugees, and persons
admitted as resident nonimmigrants who have unexpired authorized periods of admission,”
hereafter referred to as documented immigrants; and 2) unauthorized immigrants who are
“foreign born non-citizens who are not legal residents,” including recipients of Deferred Action
for Childhood Arrivals (DACA) and Temporary Protected Status, as well as those “awaiting
removal proceedings in immigration court,” hereafter referred to as undocumented immigrants
(Baker, 2021). Approximately 77% of the immigrant population in the U.S. is documented,
whereas 23% is undocumented (Bolter, 2019; Budiman, 2020). According to the U.S.
Government Information Services, there are currently three ways non-U.S.-born individuals can
obtain legal entry into the U.S.: 1) by applying for a visa (e.g., immigrant visa, visitor visa, fiancé
visa, student visa, professional visa, or transit visa); 2) by applying to enter as a refugee through

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the U.S. Refugee Admissions Program; and 3) by applying for asylum at a port of entry into the
U.S. (USAGov, n.d.).
The most common reasons immigrants give for coming to the U.S. include seeking
better opportunities for work, better living conditions, improved education, reuniting with
spouses or families, and escaping their troubled home country (Golchin, 2015). The cities of Los
Angeles, New York, and Miami are home to the majority of the U.S. immigrant population
(64%), including undocumented immigrants (Budiman, 2020). Most immigrants residing in the
U.S. are racial or ethnic minorities. Mexico (25%), China (6%), and India (6%) are among the top
birthplaces of immigrants residing in the U.S., followed by the Philippines (4%) and El Salvador
(3%) (Budiman, 2020). Furthermore, immigrants account for 81% of the U.S. Limited English
Proficiency (LEP) population (Batalova et al., 2021). Nearly 62% of immigrants residing in the
U.S. in 2019 reported speaking Spanish at home (Batalova et al., 2021). Given the breadth of
cultures, lived experiences, and group identities among immigrant populations, it is
recommended that studies interested in examining immigration as a social determinant of
health prioritize the recruitment of participants from cities with large immigrant populations,
individuals who are LEP, and racial or ethnic minorities for a representative sample. Moreover,
given the distinct classifications across immigrant groups, studies investigating immigration as a
social determinant of health should prioritize the examination of differences by documentation
status.
A Brief Overview of Undocumented Immigrants Residing in the U.S.
Experiencing problems in one’s home country leaves many foreign-born individuals with
little to no choice but to immigrate to other countries, including the U.S., in search of safety and

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support. However, U.S. immigration policies present challenges for some immigrants to enter
or remain legally in the country. Reasons for illegal or undocumented migration include
poverty, insecurity, violence, and lack of resources in one’s home country (Bolter, 2019). The
act of migration can be difficult and traumatizing. Studies have found that migrating to another
country can have various physical and psychological consequences on migrant populations,
including anxiety, aches and pains, and post-traumatic stress disorder (World Health
Organization, 2022). Despite an overall increase in migration to the U.S. across recent years,
paths for legal entry and citizenship have become more stringent and less available over time,
leaving many individuals who seek better opportunities for themselves and their families with
little choice but to enter or stay in the U.S. illegally. Furthermore, despite the U.S.’s reduction of
legal entry points, enforcement and repercussions for undocumented immigrants have
increased over time.
Due to a lack of national surveys or census data on the population, little is known about
the density and lived experiences of undocumented individuals residing in the U.S. In 2018, the
USDHS estimated that approximately 11.4 million undocumented immigrants were residing in
the U.S. (Baker, 2021). This number was determined using the “residual method,” whereby the
undocumented population is estimated as the residual number of foreign-born persons once all
other immigrant groups have been tabulated (Baker, 2021). The residual method is susceptible
to error because, as previously mentioned, there is no nationally representative survey or
census that includes information on the legal status of immigrants. Though USDHS calculations
do adjust for undercounting, there is no way to confirm the exact number of undocumented
immigrants residing in the U.S. USDHS estimates that approximately 50% of undocumented

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immigrants residing in the U.S. in 2018 were born in Mexico, though estimates show this
number has been steadily on the decline since 2010. In contrast, the number of immigrants
arriving from Asia and Central America has been slowly increasing since 2010. Furthermore, in
2018, it was estimated that 40% of undocumented immigrants were residing in California or
Texas. In fact, out of the top 20 metro areas with the largest undocumented immigrant
populations in the U.S., five were in California: San Diego, Los Angeles, Riverside-San
Bernardino, San Francisco, and San Jose (Passel, 2019).
Though limited research among the population exists, studies conducted to date have
shown that undocumented immigrants are more likely to be low income and uninsured, as well
as lack a usual source of care, compared to U.S.-born and documented immigrants (Atkins et
al., 2017; Atkins et al., 2018; Balakrishnan & Jordan, 2019; Cervantes et al., 2021; Cha et al.,
2019; Guerrero et al., 2016; Torres & Waldinger, 2015). According to the California Health
Interview survey, nearly 65% of undocumented immigrants living in California are low income,
compared to 23% of citizens and documented immigrants. Furthermore, 90% of low-income,
undocumented adults are uninsured, compared to 10% of other Californians. Almost twice as
many low-income, undocumented adults report no usual source of care (44%), compared to
other low-income Californians (24%) (Pourat, 2018). Additionally, research has found that
undocumented immigrants are more likely to be younger, working age, and men, compared to
U.S.-born and documented immigrants (Baker, 2021). The undocumented population residing
in the U.S. is distinct and experiences unique health needs as compared to their documented
and U.S.-born counterparts. Thus, as previously mentioned, it is important that studies

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exploring population and public health outcomes prioritize, whenever possible, the
examination of associations by documentation status classification.
Undocumented immigrants contribute significantly to federal, state, and local taxes yet
remain largely ineligible for public benefits. In 2017, researchers estimated that undocumented
immigrants residing in Los Angeles County alone contributed $4.43 million in state taxes and
$5.4 million in local taxes, for a total contribution of $9.9 million. Across all counties,
undocumented immigrants residing in California were estimated to have contributed $3.4
billion in state and local taxes (Wiehe, 2017). Furthermore, in 2016, a report published by New
American Economy found that undocumented immigrants contributed $13 billion to the Social
Security fund and $3 billion to Medicare (Roberts, 2019). However, because undocumented
immigrants do not have Social Security numbers and are not legally authorized to work in the
U.S., they are not eligible for Social Security benefits or Medicare. Thus, despite their significant
financial contribution to federal, state, and local governments, undocumented immigrants
remain disparaged from receiving public benefits, including health insurance coverage.
Immigration Policies in the Context of Health and Health Access
U.S. immigration policies have been discriminatory in nature since their inception.
Congress’s first immigration policy, for example, the Naturalization Act of 1790, granted U.S.
citizenship to “any free white person of ‘good character’ who [had] been living in the United
States for two years” but denied women and nonwhite residents, particularly enslaved Black
individuals, basic constitutional protection (History Network, 2022). Other early immigration
policies such as the Fugitive Slave Act of 1850, Page Act of 1875, Chinese Exclusion Act of 1882,
the Immigration Acts of 1917 and 1924, and the Immigration and Nationality Act of 1952 were

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also prejudiced against nonwhite individuals (American Battlefield Trust, 1850; Office of the
Historian, Foreign Service Institute, n.d.a; Immigration History, n.d.; Office of the Historian,
Foreign Service Institute, n.d.b, Office of the Historian, Foreign Service Institute, n.d.c). Later,
Congress replaced the immigration quota system with the Immigration and Nationality Act of
1965 with the goal of uniting immigrant families and attracting skilled immigrants to the U.S.
This bill has been credited with dramatically transforming immigration trends within the U.S.,
specifically by shifting source countries to Asia and Latin America rather than Europe (Office of
the Historian, Foreign Service Institute, n.d.a). As a result of this legislation, the number of
immigrants arriving to the U.S. each year nearly tripled by 1990. Moreover, the Immigration Act
of 1990 modified and expanded the 1965 act by increasing the number of available visas by
40%, more than doubling employment-related immigration, and retaining family reunification
as a major entry path. The expanded act also provided admission for immigrants from
“underrepresented” countries to increase the diversity of immigrants coming to the U.S.
(Center for Immigration Studies, n.d.). Though policies have slowly shifted toward less outright
discrimination against nonwhite immigrants (as in the Naturalization Act of 1790, immigration
policies have notably disparaged undocumented immigrants (Office of the Historian, Foreign
Service Institute, n.d.a; Center for Immigration Studies, n.d.).
The extent to which one’s immigration status acts as a barrier or facilitator to public
benefits and programs, including health care, is directly associated with immigration policies.
Furthermore, though U.S. immigration laws and policies have fluctuated throughout the
country’s history, they generally reflect the country’s political views toward migrants at a given
time. At present, the ability to work, access medical care, and receive public benefits in the U.S.

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is directly associated with an individual’s documentation status. Generally, undocumented
immigrants, including DACA holders, are not eligible to receive most federal public benefits,
including health insurance, food assistance, or Social Security. Conversely, documented
immigrants are eligible for federal public benefit programs if they have resided legally in the
U.S. for five years. Documented immigrants are also eligible for state-funded benefits in 26 U.S.
states, including California and New York. However, in most of these states, assistance is also
offered to individuals and families who are undocumented (National Immigration Forum, 2018).
Thus, federal and state policies generally provide greater access to public benefits and
programs to documented immigrants as compared to undocumented immigrants.
Understanding the relationship between immigration policy and immigrant health is
important because it can have a profound impact on the health and health access of immigrant
communities residing in the U.S. Studies have found that discriminatory U.S. immigration
policies result in devastating, long-term psychological and physical health consequences on the
communities they have targeted. For example, former President Franklin D. Roosevelt’s
Executive Order 9066, which ordered the forced internment of citizens and documented
residents of Japanese descent during World War II, caused irreversible psychological, physical,
and sociopolitical effects on internees (Jensen, 1998). More recently, former President Donald
Trump’s executive orders on border security, interior enforcement, and refugees and visa
holders from designated nations has left many immigrant communities, particularly Muslim and
Hispanic/Latinx populations, feeling unwelcome, unworthy, and unprotected (Center for
Migration Studies, 2017; Cohn, 2015). Recent studies have found that Trump’s anti-immigration
rhetoric, discriminatory policies, and enforcement strategies caused undocumented immigrants

8
to delay or avoid seeking mental, emergency, and social care services due to fear of discovery
and deportation (Alwan et al., 2021; Cha et al., 2019; Omar Martinez et al., 2015; Potochnick et
al., 2017; Rodriguez et al., 2019). In addition, studies have found that documentation status,
especially during times of severe anti-immigration rhetoric, affects primary, emergency, and
inpatient health-seeking processes (Nwadiuko et al., 2021). Scholars have also determined that
anti-immigration policies have negative mental health consequences on undocumented
caregivers and safety-net ED care providers (Cervantes et al., 2020; Cervantes et al., 2017;
Cervantes et al., 2018).
The effects of immigration policies and sentiments are not limited to politicians and
political discourse. In a study investigating provider perceptions of deservingness of care,
safety-net providers in Alabama often questioned immigrants’ deservingness of care (Bianchi et
al., 2019). Other studies have shown that undocumented patients’ fear of xenophobia and
stigma from their providers is associated with reduced access to health care services (Bianchi et
al., 2019; Bowen et al., 2018). Prejudiced sentiments from health care providers and the
dangerous consequences those feelings can have on undocumented immigrants are also well
documented. For example, Madrigal v. Quilligan exposed the coercive sterilization of several
low-income, immigrant women at Los Angeles County/USC Medical Center in the early 1970s
(Enoch, 2005). More recently, coerced sterilization of immigrant women at an immigrant
detention center in Georgia echoed medical personnel abuse that targets vulnerable,
undocumented women (Ghandakly & Fabi, 2021).

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The Exclusion of Undocumented Immigrants from the Affordable Care Act
As previously noted, the extent to which policies and reforms include or exclude
immigrant communities tends to reflect national sentiments around immigration at a given
time. The Affordable Care Act (ACA) and its provisions are no exception. At the time of the
ACA’s writing and proposal, policymakers were contemplating how to deal with national
concerns about terrorism and illegal immigration. In an attempt to reduce fear among citizens,
laws passed in 1996, 2002, and 2006 emphasized border control, restricted U.S. admissions
eligibility, and enforcement of laws on hiring immigrants, which further perpetuated antiimmigration sentiments (Cohn, 2015). The decision to exclude undocumented immigrants from
the ACA echoed existing anti-immigration sentiments and furthered established inequities in
public benefits, particularly health care access, among members of the undocumented
community.
Due in large part to exclusion from the ACA, undocumented immigrants’ ability to
obtain comprehensive health insurance remains extremely limited. Generally, undocumented
immigrants can obtain health insurance coverage by purchasing private insurance from
brokerages and agencies, accessing employer-sponsored programs, or accessing emergency
Medicaid. Unfortunately, these options come with several barriers and limitations. For instance,
the exclusion of undocumented immigrants from the ACA also excludes the population from
receiving the government subsidies and tax credits introduced in the policy, leaving
undocumented immigrants able to only purchase coverage directly from private insurance
providers without government financial assistance, which can be incredibly costly. Moreover,
the ability to obtain insurance coverage through employer-sponsored programs is limited

10
because participation is only required for employers with 50 or more full-time employees, and
legal employment requires proof of citizenship, which most undocumented immigrants do not
have. Though undocumented immigrants remain eligible for emergency Medicaid and other
such services, coverage is limited to emergency situations only with no coverage for follow-up
care (Keck School of Medicine, USC, 2023).
Over the last few years, California has prioritized the expansion of Medi-Cal, the state’s
Medicaid program, as well as policies to provide comprehensive health coverage to lowincome, undocumented immigrants. Until recently, Medi-Cal coverage options for
undocumented adults were limited to emergency Medi-Cal and prenatal and maternity care.
State coverage options for children were available until they reached 21 years of age. However,
Medi-Cal expansions have made it easier for low-income, undocumented immigrants to access
Medi-Cal coverage. In 2022, 286,000 low-income, undocumented older adults (aged 50 and
older) became eligible to receive full-scope Medi-Cal coverage following the implementation of
California’s Older Adult Expansion (California Department of Health Care Services, n.d.b). This
expansion was modeled after the 2020 Young Adult Expansion, which provided full-scope MediCal to low-income young adults aged 19 to 25 regardless of documentation status. In 2024, the
Ages 26 through 49 Adult Expansion is anticipated to offer low-income adults aged 26 to 49 fullscope Medi-Cal (California Department of Health Care Services, n.d.a). Though such programs
are a good start to providing comprehensive coverage to undocumented immigrant populations
residing in California, hundreds of thousands of undocumented working immigrants who do not
meet income eligibility requirements—but who do not necessarily make livable wages—will still
have few viable options for coverage. Furthermore, given underutilization of existing programs

11
aimed at offering uninsured and undocumented immigrants ambulatory care access, it is not
yet clear if the Medi-Cal expansion eligibility for low-income, undocumented immigrants will
result in a higher proportion of individuals insured through Medi-Cal.
Undocumented Immigrants and Safety-Net Services
Barriers to comprehensive insurance coverage leave many undocumented immigrants
uninsured and dependent on safety-net health systems when experiencing health care needs,
but restrictions on federal support allocation toward undocumented immigrants creates gaps in
assistance. According to a report by the Public Policy Institute of California, the California
safety-net—a complex network of programs aimed at helping low-income adults and children
meet basic needs—serves about 13.5 million residents. Three of the state’s largest programs—
Medi-Cal health insurance, CalFresh food assistance, and CalWORKs cash assistance—are
credited with reducing poverty and inequalities throughout the state by nearly 50%. The
success, expansion, and operation of safety-net offerings in California is largely dependent on
federal funding, which restricts the state’s ability to allocate federal support for the more than
two million undocumented immigrants residing in the state. Additionally, the same report
found that funding restrictions toward undocumented immigrants furthers gaps and inequities
experienced by both undocumented immigrants and families with undocumented members
(Danielson, 2021).
To reduce gaps in health care coverage, cities such as Los Angeles and San Francisco
have created locally funded initiatives, though some programs are underutilized. Programs such
as Los Angeles’s My Health LA and San Francisco’s Healthy SF were created to reduce the
impact of restrictive health policies on the health and health outcomes of ACA-ineligible

12
populations, including undocumented immigrants (McConville et al., 2015). According to the
program’s website, My Health LA (MHLA) is “a no-cost health care program for low-income
individuals who live in LA county.” Interested participants must “be between 26 and 49 years
old and unable to get insurance” (Los Angeles County Health Services, n.d.). Though the
program aims to address gaps in health care needs experienced by low-income undocumented
immigrants, it does not offer insurance coverage. Furthermore, studies have found that MHLA
program offerings are underutilized by uninsured safety-net patients due to high costs of care
and difficulty in securing appointments (Saluja et al., 2019). Reports investigating success of
programs like MHLA, which rely heavily on community health centers (CHCs), suggest that
program challenges may also be associated with underfunding (Cabral & Cuevas, 2020).
From 2011 to 2016, the ACA allocated $11 billion in funding to support the expansion of
CHCs—facilities that are important sources of ambulatory care to low-income, uninsured
populations, including undocumented immigrants. The funding was intended to expand the
number of sites, operations, and patients seen at CHCs throughout the country, which was
expected to double from 20 million in 2010 to 40 million in 2019, due in large part to the
implementation of the ACA. However, CHC expansions were hindered by federal budget cuts in
2011, which led to a $600 million deficit in funding for CHCs, or a quarter of usual federal
funding for the maintenance of CHCs. As a result, allocated CHC expansion funds were
redistributed to maintain existing CHC operations. It was projected that in the years following
the implementation of the ACA, undocumented immigrants would comprise a larger proportion
of the uninsured population and would more strongly rely on safety-net services, including
CHCs, for their care (Wallace, 2012). Thus, despite greater utilization of CHCs by recently

13
insured and continuously uninsured patients, these resources remain underfunded and in need
of improvement.
Safety-Net Literature Lacks Representation of Undocumented Immigrants
Little is known about undocumented patients’ ED care-seeking processes in the safetynet setting, including how and when patients decide to seek safety-net ED care versus
ambulatory care, including primary and specialty care. There have been recent calls to action
for more qualitative studies to include the perspectives of populations that are difficult to
reach, such as members of Latinx immigrant communities, to eliminate health inequities in the
U.S. (Greder & Reina, 2019). Various theories have been developed to describe influences of
health behaviors and outcomes in safety-net populations. However, documentation status is
notably missing from popular theoretical health utilization research studies (Gelberg et al.,
2000; Enard et al., 2018). In a scoping review of Andersen’s behavioral model of health services
use, less than half of all studies reviewed were conducted among migrant patients (Lederle et
al., 2021). Qualitative studies using grounded theory approaches have investigated facilitators
and barriers to ED care utilization in the safety-net setting, including social stigma and fear.
However, several studies focused on gathering provider narratives and perspectives, rather
than those of patients, and few focused on investigating the relationship between
documentation status and ED care-seeking processes (Alwan et al., 2021; Ornelas-Dorian et al.,
2021). Though theories have increased our understanding of the impact of perceived
discrimination and perceptions of legal status on the well-being of undocumented immigrants,
no studies have developed a theoretical framework that describes the emergency care-seeking
processes of adult safety-net patients, particularly across multiple documentation statuses

14
(Cobb et al., 2019; Cobb, Meca, et al., 2017; Cobb, Xie, et al., 2017; Cobb et al., 2016; Gelberg et
al., 2000; George et al., 2018; Hsia & Shen, 2011; Lederle et al., 2021; Loignon et al., 2015;
Quest & Marco, 2003; Waisel, 2013; Yang & Hwang, 2016). More studies that centralize
undocumented patient narratives and experiences are needed in order to further develop our
understanding of the population’s unique care needs.
Lack of representation of undocumented immigrants in the safety-net literature is not
limited to theory development or qualitative investigations; undocumented immigrants are also
underrepresented in quantitative health service studies. Large studies investigating facilitators
and barriers to primary care in the safety-net setting have not differentiated documentation
status (Shi et al., 2017). Furthermore, large studies investigating avoidable safety-net ED visits
have not included documentation status (Falik et al., 2001; Feinglass et al., 2014; GreenwoodEricksen & Kocher, 2019; Johnston et al., 2019; Kim et al., 2015; Nath et al., 2019; Oster &
Bindman, 2003; Roy et al., 2021; Schmidt et al., 2018; Tang et al., 2010).
The lack of representation of undocumented immigrants in safety-net utilization
literature may be due in part to challenges in identifying patient populations using large
datasets. Electronic health records (EHRs) offer a unique opportunity to approximate
immigration status through the creation of EHR-based algorithms. Studies that have utilized
EHR-based algorithms for approximating documentation status have had favorable agreement
(approximately 80% accuracy), particularly when including country of birth, insurance, and
Social Security number data (Heintzman et al., 2020; Ross et al., 2017). Overall, the use of Social
Security number, country of birth, and insurance data from EHRs has been successful in

15
conducting exploratory analyses of health care utilization among undocumented immigrants,
but more studies are needed to inform this approach.
The Relationship between Health Care Access and Ambulatory Care Sensitive Conditions
Undocumented immigrants experience unique barriers to ambulatory care access,
including lack of insurance coverage and high health care costs, which have life-threatening
impacts. Studies have found that undocumented immigrants residing in the U.S. feel
unsupported in their health needs due in large part to constraints in health care access, lack of
comprehensive health insurance eligibility, and little understanding of how the U.S. health care
system works (Gao et al., 2016). These limitations thus influence health outcomes within the
undocumented patient population. For example, studies have found that undocumented
immigrants are at greater risk for poor maternal health outcomes, limited access to health
insurance coverage, and low use of care as compared to documented immigrants or U.S.-born
individuals (Alberto et al., 2020; Atkins et al., 2017; Balakrishnan & Jordan, 2019; AmuedoDorantes & Lopez, 2017; Atkins et al., 2018; Cervantes et al., 2021; Cha et al., 2019).
Furthermore, undocumented immigrants report lower use of preventive health services in a
timely manner, including preventive health screenings (Guerrero et al., 2016; Torres &
Waldinger, 2015). For instance, a study of undocumented Latino men who have sex with men
found that undocumented participants had lower accessibility and use of pre-exposure
prophylaxis, despite increased risk of HIV infection (Brooks et al., 2020; Palazzolo et al., 2016;
Ross et al., 2019). Moreover, despite limited access to preventive services, undocumented
immigrants who recently arrived in the U.S. have been identified as a priority population for
primary prevention of substance abuse (Cyrus et al., 2015; Pinedo, 2020). Finally, largely due to

16
difficulties with accessing ambulatory care, undocumented patients have been found to delay
necessary care, risk premature mortality, and arrive in worse condition when seeking ED
services compared to U.S.-born and documented individuals (Madden & Qeadan, 2017; Nguyen
et al., 2019). Given their limited access to comprehensive insurance coverage and unique
challenges to receipt of ambulatory care, undocumented immigrants may be at greater risk for
utilizing safety-net EDs when experiencing ambulatory care needs due to lack of awareness of
other care options, payment flexibility, and perceived quality and convenience (Enard &
Ganelin, 2017). However, studies have not differentiated documentation status.
Researchers investigating the relationship between ambulatory care and safety-net ED
utilization may examine ED utilization for ambulatory care sensitive conditions (ACSCs). ACSCs
are “conditions for which good outpatient care can potentially prevent the need for
hospitalization, or for which early intervention can prevent complications or more severe
disease” (Agency for Healthcare Research and Quality, 2021). ACSCs are “intended to reflect
issues of access to, and quality of, ambulatory care in a given geographic area” (Agency for
Healthcare Research and Quality, 2021). Hospitalizations for conditions such as uncontrolled
diabetes, chronic obstructive pulmonary disease (COPD), asthma, heart failure, urinary tract
infections, community-acquired pneumonia, and hypertension are considered potentially
avoidable with adequate access to ambulatory care. The Agency for Healthcare Research and
Quality’s (AHRQ) composite measure of Prevention Quality Indicators (PQIs) uses the
International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)
discharge diagnosis codes to identify potentially avoidable visits or admissions for ACSCs
according to the agency’s specifications (Agency for Healthcare Research and Quality, 2021;

17
National Center for Health Statistics, 2023). Diagnosis codes determined to be ACSCs by the
AHRQ are considered avoidable visits. ACSCs are important in the safety-net setting as studies
have found that ED visits for ACSCs may have negative consequences on safety-net patients,
caregivers, and care providers, including overburdening, which can negatively affect patient
outcomes (Cervantes et al., 2020; Donoho et al., 2018; Erickson et al., 2020). Furthermore,
ACSC-related health visits are associated with higher health care expenditure for both patients
and public health systems (Hodgson et al., 2019). As previously described, due to unique
barriers to ambulatory care, undocumented immigrants may be at a greater risk for safety-net
ED utilization for an ACSC compared to their U.S.-born and documented counterparts.
However, given their lack of representation in the literature, it is unclear whether reduced
access to comprehensive health insurance coverage and limited access to ambulatory care
results in increased ED utilization for ACSCs among undocumented immigrants. More studies
investigating the relationship between documentation status and ED visit for an ACSC are
needed.
Overview and Triangulation of Studies
This dissertation conducts a comprehensive, mixed-methods investigation of
documentation status as a social determinant of safety-net ED utilization at the largest public
hospital in Los Angeles. Using a sequential design, each study informs and builds upon the
others. Qualitative findings from study 1 inform the quantitative research question investigated
in study 2, and results from studies 1 and 2 inform and contextualize the qualitative secondary
analysis performed in study 3. Using a grounded theory approach, the first study develops a
theoretical framework of safety-net ED care-seeking processes described by safety-net patients

18
during semistructured interviews (n=25) and highlights distinct influences of ED care-seeking
processes described by undocumented patients. It was anticipated that themes related to
ambulatory care access that influence undocumented patients’ safety-net ED care-seeking
processes would emerge from the data. The second study uses multivariate logistic regression
to investigate the association between documentation status and ED visit for an ACSC in a
sample of n=129,834 safety-net ED patients at the largest public hospital in Los Angeles
between 2016 and 2019. It was hypothesized that undocumented immigrants would have
higher odds of ED utilization for an ACSC compared to U.S.-born individuals. Study 3 integrates
results from studies 1 and 2 to conduct a qualitative secondary analysis of the original
theoretical framework. It was anticipated that undocumented patients whose ED visit pertained
to an ACSC would describe distinct safety-net ED care-seeking processes from those whose ED
visit did not pertain to an ACSC. Figure 1 presents a conceptual model of the dissertation
studies.
Figure 1. Conceptual Model of Dissertation Studies Using a Sequential Mixed-Methods Design
Note. Adapted from “General Diagrams of the Three Core Designs,” by J. W. Creswell and V. L. Plano Clark, 2011,
Designing and conducting mixed methods research, 3rd edition, p. 66. Copyright 2011 by Sage.

19
Implications of Proposed Studies
The studies in this dissertation aim to provide a more comprehensive understanding of
documentation status as a social determinant of safety-net ED utilization. Results will highlight
convergences and divergences in undocumented safety-net patients’ emergency care-seeking
processes as compared to those described by U.S.-born and documented patients, as well as
distinct influences of ED care-seeking described by undocumented patients. One of this
dissertation’s greatest strengths is in its investigation of safety-net ED care utilization in the
largest public hospital in Los Angeles, home to one of the largest undocumented immigrant
populations in the U.S. Additionally, this dissertation aims to address gaps in the existing
literature by: 1) developing a theoretical framework of emergency care-seeking processes
described by safety-net ED patients while highlighting distinct processes described by
undocumented patients; 2) investigating the association between documentation status and
safety-net ED utilization for an ACSC; and 3) integrating qualitative and quantitative research
methods to conduct a qualitative secondary analysis of safety-net ED utilization processes
among undocumented immigrants with an ACSC and those seen for other conditions. This
dissertation centers patient narratives and experiences through the collection and integration
of semistructured interviews with quantitative results. Furthermore, results will inform future
research and recommendations for reducing inequities in health and health access experienced
by undocumented immigrants residing in Los Angeles.

20
Chapter 2: A Grounded Theory Approach to Understanding the Emergency Care-Seeking
Processes of Documented and Undocumented Safety-Net Patients at an Urban Safety-Net
Hospital in Los Angeles: A Qualitative Analysis
Study Objective
The goal of this investigation is to use a grounded theory approach to develop a theory
of emergency care-seeking processes described by safety-net patients, while highlighting the
distinct ED care-seeking processes described by undocumented patients.
Background
In 2018, the United States Department of Homeland Security estimated that
approximately 11.4 million undocumented immigrants were residing in the U.S. (Baker, 2021).
Though limited research among the population exists, studies conducted to date have shown
that undocumented immigrants are more likely to be low income and uninsured, as well as lack
a usual source of care, use fewer preventive health services, and report poor health outcomes
as compared to their U.S.-born and documented counterparts (Atkins et al., 2017; Atkins et al.,
2018; Balakrishnan & Jordan, 2019; Cervantes et al., 2021; Cha et al., 2019; Guerrero et al.,
2016; Torres & Waldinger, 2015). Due in large part to exclusion from the ACA, undocumented
immigrants’ ability to obtain comprehensive health insurance remains extremely limited.
Barriers to health care coverage leave many undocumented immigrants uninsured and
dependent on safety-net health systems when experiencing health care needs. Despite their
unique care needs, little is known about undocumented patients’ ED care-seeking processes in
the safety-net setting, including how and when patients decide when and where to seek safetynet ED care versus ambulatory care, such as primary and specialty care.

21
Methods
Eligible ED patients participated in a 30-minute face-to-face interview. English- and
Spanish-language approach scripts and interview guides were developed prior to participant
recruitment. All interviews were audio-recorded and conducted by bilingual, trained members
of the research team who had previous qualitative research experience. Our study codebook
was derived from the data based on analysis of the semistructured interviews and emerging
themes related to influences on participants’ ED care-seeking processes. Multiple coders and
intercoder reliability (ICR) scoring were used to limit subjective biases in the coding process.
The research team conducted four rounds of independent coding with comparison for the
development of the current codebook, which indicates excellent agreement (pooled K=0.94).
The codebook contains seven axial themes and 17 subthemes that describe factors that
influence participants’ ED care-seeking processes.
Results
Choosing to seek ED care is a complicated process that is influenced by multiple factors.
Patients we interviewed described noticing symptoms, delaying ED care, prompting ED care,
and choosing where to seek ED care prior to finally seeking ED care. Additionally,
undocumented participants described emergency care-seeking processes distinct from those of
their U.S.-born and documented counterparts. Undocumented participants who delayed ED
care-seeking often did so by first seeking other forms of care, particularly ambulatory care at
CHCs. Undocumented participants described being prompted to seek ED care following failed
attempts to seek ambulatory care and when referred by ambulatory care providers.

22
Undocumented patients we interviewed also described seeking tolerant providers and greater
access to specialty care and equipment when deciding where to seek ED care.
Conclusions
We found that safety-net ED patients experienced similar emergency care-seeking
processes to those in non-safety-net settings. Furthermore, we found that U.S.-born,
documented, and undocumented patients shared some similarities in their safety-net ED careseeking processes, though distinctions were also noted. Our study found that when
undocumented immigrants attempted to bridge gaps in ambulatory care access by seeking care
at CHCs, they encountered scheduling difficulties, understaffing, unresolved symptoms, and
costly care. Though undocumented patients preferred the convenience of scheduled
appointments and short wait times that ambulatory care offers, they described being left with
no choice but to seek ED care when ambulatory care services, particularly CHCs, could not meet
their needs. Our findings indicate that existing programs aimed at reducing gaps in ambulatory
care access experienced by uninsured patients, particularly undocumented immigrants, are a
good starting point and could benefit from engaging members of the community in discussions
and future research to improve engagement, quality, and access.

23
Introduction
In 2018, the United States Department of Homeland Security estimated that
approximately 11.4 million undocumented immigrants were residing in the U.S. (Baker, 2021).
Furthermore, in 2018, it was estimated that 40% of undocumented immigrants were residing in
California or Texas. In fact, out of the top 20 metro areas with the largest undocumented
immigrant populations in the U.S., five were in California: San Diego, Los Angeles, Riverside-San
Bernardino, San Francisco, and San Jose (Passel, 2019). Though limited research among the
population exists, studies conducted to date have shown that undocumented immigrants are
more likely to be low income and uninsured, as well as lack a usual source of care, compared to
U.S.-born and documented immigrants (Atkins et al., 2017; Atkins et al., 2018; Balakrishnan &
Jordan, 2019; Cervantes et al., 2021; Cha et al., 2019; Guerrero et al., 2016; Torres & Waldinger,
2015). Undocumented immigrants are also more likely to be uninsured, use fewer preventive
health services, and report poor health outcomes as compared to their documented
counterparts (Atkins et al., 2017; Atkins et al., 2018; Balakrishnan & Jordan, 2019; Cervantes et
al., 2021; Cha et al., 2019; Guerrero et al., 2016; Torres & Waldinger, 2015). Furthermore,
barriers to ambulatory care access, including primary care, may place undocumented
immigrants at a greater risk for developing chronic conditions that are associated with lifestyle
risk factors, including type 2 diabetes mellitus or high cholesterol, as compared to U.S.-born
individuals. Additionally, undocumented patients have been found to delay necessary care, risk
premature mortality, and arrive in worse condition when seeking ED services (Madden &
Qeadan, 2017; Nguyen et al., 2019). According to the California Health Interview survey, nearly
65% of undocumented immigrants living in California are low income, compared to 23% of

24
citizens and documented immigrants. Furthermore, 90% of low-income, undocumented adults
are uninsured, compared to 10% of other Californians. Almost twice as many low-income,
undocumented adults report no usual source of care (44%), compared to other low-income
Californians (24%) (Pourat, 2018). Additionally, research has found that undocumented
immigrants are more likely to be younger, working age, and men, compared to U.S.-born and
documented immigrants (Baker, 2021). The undocumented population residing in the U.S. is
distinct and experiences unique health needs as compared to their documented and U.S.-born
counterparts. As a result, studies exploring population and public health outcomes should
prioritize, whenever possible, the examination of associations by documentation status
classification.
Due in large part to exclusion from the ACA, undocumented immigrants’ ability to
obtain comprehensive health insurance remains extremely limited. Though undocumented
immigrants remain eligible for emergency Medicaid and other such services, coverage is limited
to emergency situation with no coverage for follow-up care (Keck School of Medicine, USC,
2023). Barriers to comprehensive insurance coverage leave many undocumented immigrants
uninsured and dependent on safety-net health systems when experiencing health care needs.
Restrictions on federal support allocation toward undocumented immigrants creates gaps in
assistance. According to a report by the Public Policy Institute of California, the California
safety-net—a complex network of programs aimed at helping low-income adults and children
meet basic needs—serves about 13.5 million residents. Three of the state’s largest programs—
Medi-Cal health insurance, CalFresh food assistance, and CalWORKs cash assistance—are
credited with reducing poverty and inequalities throughout the state by nearly 50%. The

25
success, expansion, and operation of safety-net offerings in California is largely dependent on
federal funding, which restricts the state’s ability to allocate federal support for the more than
two million undocumented immigrants residing in the state. Additionally, the report found that
funding restrictions toward undocumented immigrants furthers gaps and inequities
experienced by undocumented immigrants and families with undocumented members
(Danielson, 2021).
To reduce gaps in health care coverage, cities such as Los Angeles and San Francisco
have created locally funded initiatives, though some programs are underutilized. Programs such
as Los Angeles’s My Health LA and San Francisco’s Healthy SF were created to reduce the
impact of restrictive health policies on the health and health outcomes of ACA-ineligible
populations, including undocumented immigrants (McConville et al., 2015). Though the MHLA
program aims to address gaps in health care needs experienced by low-income undocumented
immigrants, it does not offer insurance coverage. Furthermore, studies have found that MHLA
program offerings are underutilized by uninsured safety-net patients due to high costs of care
and difficulty with securing appointments (Saluja et al., 2019). Reports investigating success of
programs like MHLA, which rely heavily on CHCs, suggest that program challenges may also be
associated with underfunding (Cabral & Cuevas, 2020).
Little is known about undocumented patients’ ED care-seeking processes in the safetynet setting, including how and when patients decide when and where to seek safety-net ED
care versus other forms of care, including ambulatory care. There have been recent calls to
action for more qualitative studies to include the perspectives of populations that are difficult
to reach, such as members of Latinx immigrant communities, to eliminate health inequities in

26
the U.S. (Greder & Reina, 2019). Various theories have been developed to describe health careseeking processes and health outcomes in safety-net populations. However, documentation
status is notably missing from popular theoretical health utilization research studies (Gelberg et
al., 2000; Enard et al., 2018). In a scoping review of Andersen’s behavioral model of health
services use, less than half of all studies reviewed were among migrant patients (Lederle et al.,
2021). Qualitative studies using grounded theory approaches have investigated facilitators and
barriers to ED care utilization in the safety-net setting, including social stigma and fear.
However, several studies gathered provider narratives and perspectives, rather than those of
patients, and few investigated the relationship between documentation status and ED careseeking processes (Alwan et al., 2021; Ornelas-Dorian et al., 2021). Though theories have
increased our understanding of the impact of perceived discrimination and perceptions of legal
status on the well-being of undocumented immigrants, no studies have developed a theoretical
framework that describes the emergency care-seeking processes of adult safety-net patients,
particularly across multiple documentation statuses (Cobb et al., 2019; Cobb, Meca, et al.,
2017; Cobb, Xie, et al., 2017; Cobb et al., 2016; Gelberg et al., 2000; George et al., 2018; Hsia &
Shen, 2011; Lederle et al., 2021; Loignon et al., 2015; Quest & Marco, 2003; Waisel, 2013; Yang
& Hwang, 2016). More studies that centralize undocumented patient narratives and
experiences are needed in order to further develop our understanding of the population’s
unique care needs.

27
Goals of This Investigation
The goal of this investigation is to use a grounded theory approach to develop a theory
of emergency care-seeking processes described by safety-net patients, while highlighting the
distinct care-seeking processes described by undocumented patients.
Methods
All study procedures were conducted by a research team composed of a PhD student
(C.N.R.), emergency medicine physician (E.B.), two medical students (V.G. and R.S.), and four
undergraduate students. All interviews were conducted under the supervision of the primary
author, who identified as a cisgender Hispanic woman and had extensive experience in
qualitative research. All interviewers, transcribers, and translators on the research team
identified as Hispanic/Latinx and native Spanish speakers. All interviewers received a minimum
of two training sessions and a mock interview with feedback prior to engaging in study activities
by the principal investigator (E.B.) and first author (C.N.R.). Members of the research team were
educated about the goals of the research project and trained on all research procedures in a
systematic manner. To promote reflexivity and reduce bias, all team members were
encouraged to reflect on their interactions, assumptions, and presuppositions throughout the
data collection and analysis process via writing of analytic memos. Members of the research
team also participated in weekly meetings to touch base on study progress, share reflections
and experiences during data collection, and collaborate on data analysis and interpretation.
Prior to study commencement, members of the research team had no established relationships
with participants.

28
Study Design
Setting. All study procedures were conducted at the largest public hospital and Level I
trauma center ED in Los Angeles, California. The participating ED is part of one of the largest
county-run health care systems in the nation and serves an ethnically diverse and historically
marginalized patient population. Ethical standards were upheld using informed consent and
confidentiality, and participants were able to withdraw from study activities at any time. The
institutional review board of the University of Southern California approved all study
procedures (HS-16-00742).
Theoretical Framework and Participant Selection. We used a qualitative grounded
theory approach to develop a theory of emergency care-seeking processes as described by
undocumented and documented adult safety-net patients. This approach was selected for its
distinct feature of the systematic collection and analysis of qualitative data using theoretical
sampling, constant comparison, and theoretical saturation (Glaser, 1992; Strauss & Corbin,
1994). Participant recruitment and data analysis began in February 2019, was interrupted by
the COVID-19 pandemic in March 2020, and restarted in March 2022. Study recruitment
concluded in August 2022 at the point of theoretical saturation—or when further data no
longer developed new or deviated concepts in the developing theory (Charmaz, 2014).
Recruitment took place among patients who were 18 years or older, were pending
admission to the inpatient hospital, and had an Emergency Severity Index (ESI) score of 3 or
greater (used as a proximal measure of acuity) (Agency for Healthcare Research and Quality,
2020). Their reason for admission included medical problems that sufficient enough to require
ED care but not critical to the point where they could not participate in study activities (e.g.,

29
abdominal pain, distention, or discomfort, nausea/vomiting, et cetera). Patients who spoke
English or Spanish and whose provider signed off on their mental and physical ability to
participate in a 30-minute interview were approached and invited to participate in a face-toface interview. Interviewers approached potential participants at their bedside in the ED while
patients waited for an inpatient hospital bed, a wait which took several hours to days for some
patients. Interviewers provided a brief verbal description of the study in lay language and asked
patients if they were interested in participating. Patients who agreed to participate were
counseled through the informed consent process and provided a written copy of all informed
consent documentation prior to beginning the interview.
Data Collection. English- and Spanish-language approach scripts and interview guides
were developed prior to participant recruitment to provide study personnel with standardized
language for recruitment and participation efforts. Approach scripts were used to share study
objectives, participation, and implications with eligible ED patients. Interview guides explored
participants’ views, experiences, and decision-making processes related to seeking emergency
services through open-ended interview questions and probes. Open-ended interview questions
explored sociocultural and structural influences, including social support and insurance, on
patients’ emergency care-seeking behaviors. Interview questions encouraged informal,
conversational discussion between the participant and interviewer and were designed to
empower participants to “set the tone and pace of the interview,” as is traditional in grounded
theory research (Charmaz, 2014). Probes were written to facilitate exploration of emerging
concepts throughout the data collection process.

30
Study approach scripts and interview guides underwent multiple rounds of revision and
piloting throughout the data collection and analysis process. Revisions identified and resolved
issues of organization and language, addressed gaps in the developing theory, and explored
new and emerging themes. All revisions were resolved via consensus among members of the
research team. Additional piloting was conducted for Spanish-language approach scripts and
interview guides to ensure translations were appropriate and culturally competent. Study
personnel piloted the Spanish-language interview guide and approach script with native
Spanish-speaking ED research staff who had not read the initial English version of the
documents. Piloting identified and resolved any issues related to translation and cultural
competence. Table 1 provides a sample approach script. Table 2 provides sample interview
guide questions.
Table 1. Sample Approach Script
Hello Mr./Ms._ [patient’s last name] _,
My name is _ [researcher’s name) _, I am a _ [researcher’s title] _. I’m studying the
experiences of patients visiting the emergency department and was wondering if I could have
a couple minutes of your time to tell you about the study in case you may be interested in
participating?
If you decide to participate in the study, I will ask you several questions on your experience
using medical services today and in the past. You would also receive a gift card for your time.
Your responses to my questions will be audio-recorded and combined with other patients’
responses to better understand the experiences of patients visiting the emergency
department. In the case that any of my questions make you uncomfortable, you may choose
to skip the question or terminate the interview all together without any effect to your
medical attention today or in the future. To maintain your privacy, I would not register your
name or other personal information during the interview. All the information that you were
to share with me would not be shared with anyone outside of the study team. Your
participation would be completely voluntary, you can choose not to participate, and your
decision would not affect your medical care today or in the future. Would you like to
participate in the study?

31
Table 2. Sample Interview Questions and Probes
1. Can you please describe the events that led to your emergency department visit today?
a. How were you feeling in the days [or hours] before coming in?
b. When did you first experience or notice your symptoms? What was running through
your mind in those moments? When, if ever, had you previously experienced these
symptoms?
c. What, if anything, helped you feel better [or worse]?
2. How long did you wait after you first felt ill/in pain before coming to the ED?
a. What were your reasons for waiting?
b. How did you pass the time?
c. How did you know it was time to seek ED care?
3. What, if anything, influenced your decision to come to this ED for care?
a. What was running through your mind when deciding where to get emergency care?
b. Where, if anywhere, else did you consider going to for care?
4. What, if anything, helped you decide where to seek care?
a. What, if anything, made it difficult to decide where to seek care?
5. What, if any, previous experience(s) did you have visiting or receiving care at this ED prior
to today?
a. How, if at all, did your previous care-seeking experiences influence your decision to seek
care here today?
6. What else would you like me to know to better understand the experiences of patients
using emergency services?
All interviews were audio-recorded and conducted by bilingual, trained members of the
research team who had previous qualitative research experience. Participants’ semistructured
interviews took approximately 30 minutes to complete. Interviews were conducted face-to-face
in participants’ preferred language using the prewritten interview guides. At the conclusion of
the interview, participants received a $10 gift card. Participants’ demographic and clinical
information—including sex, age, documentation status, clinical acuity, reason for visit,
preferred language, race, ethnicity, and insurance type—were gathered at the conclusion of the
interview via self-report and medical record abstraction. All demographic information was
uploaded and stored on a HIPAA-compliant, password-protected virtual database provided by
the participating institution. Documentation status was captured via self-report during the

32
interview using a brief, six-item questionnaire adapted from RAND’s LA Family and
Neighborhood Survey (RAND Corporation, 2018). Participants were reminded of their right to
confidentiality and empowered to execute their right to refuse to answer or disclose any
personal information that made them uncomfortable prior to the collection of documentation
status information. Participants who reported being born either in the U.S., or outside the U.S.
but who had permanent residence, visa, or other temporary permission to live or work in the
U.S., were classified as documented. Participants who were born outside the U.S., lacked
permanent residence, and did not have a visa or other temporary permission to live or work in
the U.S. were classified as undocumented. Table 3 provides a sample of questions used to
capture participants’ documentation status.
Table 3. Sample Documentation-Status Questions
1. In what country were you born?
2. Are you a citizen of the United States?
a. If YES: For how many years?
b. If NO: Are you a permanent resident of the United States? [“People usually call this a
‘Green Card,’ but the color can also be pink, blue, or white.”]
i. If YES: How many years have you had a green card or been a permanent resident?
ii. If NO: Do you currently have a visa or other temporary permission to live or work in the
United States?
Data Analysis
Interviews were transcribed and translated into English, then reviewed for accuracy by
multiple members of the research team. Constant comparison was used to develop categories,
concepts, themes, codes, and subcodes to generate theories. Analytic memos were used to
provide detailed records of the researchers’ thought processes, reflections, and changes in
sampling approaches as well as guide coders through the constant comparative iterative

33
process. Coding and analysis were conducted using Dedoose analytic software (Dedoose
Support, n.d.). A set of codes and subcodes, or the study codebook, was derived from the data
based on analysis of the semistructured interviews and emerging themes related to influences
on patients’ ED care-seeking processes. Multiple coders and ICR scoring were used to limit
subjective biases in the coding process. An ICR score of 85% or greater agreeability was used
throughout the coding process, as is favorable in qualitative research (O’Connor & Joffe, 2020).
The research team conducted four rounds of independent coding with comparison for the
development of the current codebook, which indicates excellent agreement (pooled K=0.94).
The codebook contains seven axial themes and 17 subthemes that describe factors influencing
patients’ ED care-seeking process. The study was considered complete at the point of
theoretical saturation.
Results
Recruitment
Throughout the study period, a total of 84 ED patients were eligible for recruitment.
Thirty-five patients were eligible but were not approached for recruitment. Reasons eligible
patients were not approached included another interview happening at the same time, patient
not being in the room when interviewer approached, and patient reporting being too sick to
participate. A total of 49 patients were approached and invited to participate in study activities.
Out of those approached for recruitment, 22 chose not to participate. Twenty-seven patients
were approached and successfully enrolled in study activities. Two interview audio files were
lost and unavailable for analysis due to technical difficulties. Three participants were

34
interviewed with a partner, friend, or family member present in the room. Figure 2 presents a
strobe diagram of our study recruitment efforts.
Figure 2. Strobe Diagram of Study Recruitment Efforts
Participant Characteristics
Our final analytic sample size was composed of 25 safety-net ED patients, 10 of whom
identified as undocumented, and 15 as documented (n=7 foreign-born documented and n=8
U.S. born). All participants who were interviewed disclosed their documentation status.
Participants were predominantly Hispanic/Latinx and insured through Medi-Cal. Thirteen
participants identified as men and 12 identified as women. Participant ages ranged from 27 to
78 years with a mean age of 49 years (SD 13.08). Mean ESI among study participants was 2.8,
indicating that patients were being seen for medium-risk situations with moderate levels of
pain or distress. Participants’ self-reported countries of birth included Mexico (56%), U.S. (32%),
El Salvador (1%), Honduras (1%), and Colombia (1%). Mean age among undocumented

35
participants was 51 years old. All undocumented participants identified as Hispanic/Latinx and
were predominantly Spanish speaking. Most undocumented participants were insured through
Emergency or Restricted Medi-Cal and were born in Mexico. Table 4 presents participant
characteristics by documentation status.
Table 4. Participant Characteristics
Characteristic
All study
participants
n=25 (%)
Undocumented
participants
n=10 (%)
Documented
participants
n=15 (%)
Sex
Woman 12 (48.00) 4 (40.00) 8 (53.33)
Man 13 (52.00) 6 (60.00) 7 (46.67)
Age
Range 27–78 39–72 27–78
Mean (SD) 49.28 (13.08) 50.5 (9.94) 48.47 (15.09)
Emergency severity index
(ESI)
Range 2–3 2–3 2–3
Mean (SD) 2.84 (0.37) 2.8 (0.42) 2.87 (0.35)
Race/ethnicity
Hispanic/Latinx 19 (76.00) 10 (100.00) 9 (60.00)
Hispanic American Indian or
Alaska Native 1 (4.00) 0 (0.00) 1 (6.67)
Hispanic White 1 (4.00) 0 (0.00) 1 (6.67)
Non-Hispanic Black or African
American 4 (16.00) 0 (0.00) 4 (26.67)
Insurance type
Presumptively eligible for
Medi-Cal 2 (8.00) 2 (20.00) 0 (0.00)
Emergency/Restricted
Medi-Cal 7 (28.00) 5 (50.00) 2 (13.33)
Medicaid, including Medi-Cal 12 (48.00) 3 (30.00) 9 (60.00)
Medicare 3 (12.00) 0 (0.00) 3 (20.00)
Private 1 (4.00) 0 (0.00) 1 (6.67)
Language of interview
Spanish 17 (68.00) 10 (100.00) 7 (46.67)
English 8 (32.00) 0 (0.00) 8 (53.33)
Country of birth
Mexico 14 (56.00) 9 (90.00) 5 (33.33)

36
US 8 (32.00) 0 (0.00) 8 (53.33)
El Salvador 1 (4.00) 0 (0.00) 1 (6.67)
Honduras 1 (4.00) 1 (10.00) 0 (0.00)
Colombia 1 (4.00) 0 (0.00) 1 (6.67)
General Influences of ED Care-Seeking
Experiencing Symptoms and Assessing Severity. Both undocumented and documented
participants described the ED care-seeking process as beginning with patients experiencing
symptoms and assessing severity. Participants described symptoms as a range of physiological
and functional changes to the body, including changes in appearance (bruising, discoloration,
fluid loss or retention), energy levels (exhaustion, weakness, fatigue), consciousness, and pain.
Participants considered the timing and intensity of symptom onset when assessing severity.
Symptoms that onset quickly and with high intensity such as loss of consciousness, blood loss,
and difficulty breathing were generally perceived to be life threatening. In these situations,
participants took immediate action and were brought to the ED via emergency medical services
(EMS) (n=4) or given a ride from a friend or relative. Participants who did not perceive their
symptoms to be life threatening chose not to take immediate action or waited to seek care in
hopes of symptom resolution without the need for medical treatment, hereafter referred to as
delaying ED care.
Delaying ED Care. Documented and undocumented participants engaged in various
coping mechanisms to manage their symptoms while delaying ED care, including self-treatment
such as taking over-the-counter pain medications and drinking herbal teas. Many participants
had previous experience with their symptoms and recalled those experiences for ideas on how
to manage and resolve their current symptoms. Some participants sought advice by calling

37
friends, family, or primary and specialty care providers for recommendations on treating their
symptoms. Other participants described coping with their symptoms by ignoring or avoiding
thinking about them altogether. Participants described waiting several hours, days, or weeks for
their symptoms to resolve before ultimately seeking ED care.
Reasons for delaying ED care were varied and intersecting. Participants described
delaying ED care to avoid inconveniences associated with care-seeking, including long wait
times, transportation barriers, invasive or painful medical treatments, and anticipated provider
judgment. Several participants who described delaying ED care to avoid provider judgment
identified as racial or ethnic minorities experiencing homelessness and/or substance misuse.
Participants often felt torn between seeking treatment and tending to important obligations
such as caring for dependents or working. Participants who delayed ED care did not believe
their symptoms warranted the potential time spent waiting to be seen or treated and preferred
to wait for symptoms to resolve on their own. Participants were further incentivized to delay
ED care when experiencing transportation barriers such as lack of access to a motor vehicle.
Participants also described wanting to avoid feelings of helplessness that they often associated
with seeking medical care.
Prompting ED Care. Undocumented and documented participants were prompted to
seek ED care when their symptoms worsened or remained unresolved. Participants considered
symptoms of worsening pain, fluid loss, fatigue, loss of consciousness, and shortness of breath
to be life threatening or severe. Symptoms of unresolved pain, nausea, and inability to perform
essential day-to-day functions and tasks (e.g., walking, eating, or working) were considered to
be unmanageable. Participants also described other individuals acting as catalysts for their

38
emergency care-seeking. Many participants were prompted to seek ED care when a trusted
member of their social networks, including friends, family, and primary or specialty care
providers, expressed concern for their changed or declining health status. Other participants
recalled being motivated to seek ED care after thinking about how their compromised health
might negatively impact the lives of their friends and family, including children, spouses, and
grandchildren. Participants also described worrying that their symptoms could result in
permanent disability or death, which would mean they would no longer be able to provide for
their families. Once determining their symptoms to be severe or unmanageable, some
participants chose to seek ED care immediately. Other participants chose not to seek care right
away and contemplated where to seek ED care.
Choosing Where to Seek ED Care. Documented and undocumented participants who
did not take immediate action when prompted to seek ED care contemplated where to seek ED
care. Participants preferred to visit EDs where they anticipated interacting with friendly and
thorough providers, receiving timely care, and achieving symptom resolution. Participant
expectations of ED service and treatment were informed by their own previous ED care-seeking
experiences or those of someone they know. Participants preferred to seek ED care where they
or someone they know had been treated previously and left satisfied with their care and
treatment outcomes. When evaluating ED care and service, participants considered providers’
bedside manner (e.g., welcoming, friendly, patient), thoroughness (e.g., obtaining a detailed
health history), and symptom management or resolution (e.g., reducing or eliminating
symptoms, developing detailed treatment plan). Participants regarded anticipated ED service
and care so highly that they described being willing to travel further distances to receive care at

39
EDs they trusted rather than at EDs closer in proximity but perceived to offer less favorable
service and care. Participants avoided EDs they perceived to have unfriendly providers and
rushed care.
Participants also preferred to visit EDs where they are empaneled and near their area of
residence. Participants favored empanelment—having established care and medical records
within a specific hospital system—when deciding where to seek ED care. Participants preferred
to seek ED care at hospital systems where they are empaneled because they perceived that
these systems promote continuity of care. Participants described avoiding seeking ED care at
facilities where they were not empaneled because they did not want to feel like they were
sharing their medical history from the beginning. Participants felt more comfortable seeking ED
care at locations where they had an established medical history and rapport. When given the
choice to seek ED care at a facility close to their residence or at an ED farther from their
residence but where they were already empaneled, several participants described opting to
travel further for empanelment. Participants also preferred to visit EDs that were local, or near
their place of residence, and convenient to locate (e.g., walking or driving distance). Table 5
presents themes and supportive quotes from participants related to the ED care-seeking
processes described above.
Table 5. Themes and Supportive Quotes of General Influences of ED Care-Seeking
Themes Supportive quotes
Perceiving symptoms to be
life threatening, severe, or
manageable when
experiencing symptoms and
assessing severity
Perceiving symptoms to be life threatening or severe
“The intensity of the pain was so bad this morning. I was
writhing and moaning and groaning over it. And, yeah, I just
decided that this isn’t a regular doctor’s visit or even urgent
care, you know? It just felt really terrible. I mean, 10/10 pain
on the 10 scale, so yeah, that’s what really made me decide to
come here.”

40
—non-Hispanic Black/African American man, 29, documented
“Not to be too graphic, but when blood comes into play, like
when there’s blood where there shouldn’t be, that’s a pretty
defining moment . . .”
—Hispanic man, 38, documented
Perceiving symptoms to be manageable
“[I waited to seek ED care] because previously I had a bit of
pain, but it went away. That’s what I was waiting for. I said,
‘Maybe I am going to have pain right now and in a little while
it will go away . . .’ I had felt [the] pain before but it went
away, and I thought it was going to be the same this time.”
—Hispanic man, 54, undocumented
“I would get pain and it would go away, I would get pain and
it would go away. Then, after some time, I would get [pain]
and it would not go away.”
—Hispanic woman, 35, documented
Reasons for delaying ED care Coping with symptoms
“I started getting abdominal pain and it wasn’t going away. I
took some chamomile tea, which usually works. Last week I
had them [the same symptoms] and with the tea they went
away.”
—Hispanic man, 27, documented
“I would take natural things. My daughters make me my teas
at night . . . I also took Advil every eight hours.”
—Hispanic woman, 55, documented
“I took analgesics since I’ve already had a little experience
with them because I had an infection in my foot from an
ulcer. I did what I had to do. I cleaned the wound myself
because I have cleaning supplies. Cleaned it [the wound] and
tried to do something that would alleviate my pain.”
—Hispanic woman, 41, undocumented
Avoiding inconveniences associated with ED care-seeking
“Knowing that it was going to take a long time to be seen was
one of the reasons why I didn’t really want to come here [the
ED].”
—Hispanic man, 54, undocumented
“I noticed my health problems started about a month ago . . .
Part of coming to the hospital for a visit is knowing that you’re
in for a wait. [Coming to the ED] is a very time-consuming

41
thing. So, when I first found out that there was something
wrong with me, it was easy to set it aside, like, ‘Oh, I’ll go next
week,’ or ‘I’ll go tomorrow,’ you know? Usually when you
come for an ED visit, you know you're going to be there all
day. It’s the thing that really holds you back from actually
coming to the hospital, knowing that it’s pretty much going to
be an all-day thing.”
—Hispanic man, 38, documented
“Since they did the last operation on me where I almost died,
I’ve been terrified to come to the doctor . . . I almost died in a
hernia operation, and they never told me what happened or
anything. I woke up in pain, and it scared me.”
—Hispanic woman, 55, documented
“I was afraid that if I sought care they were going to operate
on me . . . I wasn’t afraid of the personnel, no. I wasn’t afraid
of the doctors either. I was scared that they were going to
operate on me. That was the only thing I was afraid of.”
—Hispanic woman, 78, documented
“I just was spooked to call for an ambulance at first because I
didn’t know if they [the doctors] were going to say, ‘You just
got out here [the ED] yesterday, there’s nothing wrong with
you,’ but there is something wrong and I don’t know what it
is.”
—Black/African American man, 40, documented
Reasons that prompt ED care Worsening or unresolved symptoms
“The abdominal pain went away until yesterday. It got worse.
It got to the point where I threw up and I knew I had to go to
the emergency room. This is not normal no more.”
—Hispanic man, 27, documented
“I said, ‘It [the pain] will probably pass by the end of the day.
It’ll pass, it’ll pass.’ I went and waited for those two days but I
noticed that no, it [the pain] didn’t pass. It didn’t become
controlled, not the pain nor my breathing. That’s why I
decided to come back here [the ED].”
—Hispanic man, 46, undocumented
Prompting by others
“I thought that I had something, maybe that my kidneys were
failing. Since I have diabetes, I thought to myself, maybe
something is complicating in my kidneys. So, then my brother
told me that I had to go to the doctor, because they [the

42
doctors] had to check me, to see what was happening. That is
why I decided to come here [the ED].”
—Hispanic woman, 45, documented
“Yesterday the bleeding got worse. I waited for my husband
to get home and told him to bring me here [the ED].”
—Hispanic woman, 55, documented
Choosing where to seek ED
care
Previous positive care-seeking experiences
“I know here at [hospital name redacted] they have good
doctors and they take good care of their patients here. ’Cause
I already came in once for my broken hand and they took
good care of me. So, I’m like, why am I going to go
somewhere else when right here they do a good job?”
—Hispanic man, 27, documented
“I chose to come here instead of somewhere close to my
house because I’ve been here before and they treat me well.
That’s why I come . . . I feel more confident about getting my
care here.”
—Hispanic woman, 78, documented
“I have history here. My parents both had a medical
procedure done here. Last weekend I was in another
emergency room with someone else, like accompanying
them, and I didn’t like the atmosphere. It was an obvious
choice to come here . . . I knew what to expect because I’ve
been here before. At the other place [ED], it was like there
wasn’t a clear way to get the ball rolling. People were waiting
way longer than us and [there] didn’t seem to be anything
that differentiated how severe people were. They were just
kind of huddled around. That’s why I chose to come here.”
—Hispanic man, 38, documented
“I give high marks to [hospital name redacted] even though
it’s a county hospital, you know what I’m saying? I’m
connected with the right professional that can really get down
to checking and resolving my symptoms or at least sending
me around to get my issues resolved. I’m real confident in the
staff and different departments they have here. I’m confident
I’m in the right place. I’m in the right place.”
—non-Hispanic Black/African American man, 62, documented
Empanelment and proximity
“I already have all my arrangements and paperwork here; it’s
easier. Like right now when I came, I just came through the

43
entrance over there, I registered, and they passed me through
to here. I waited like 10 minutes and then they gave me the
room.”
—Hispanic man, 54, undocumented
“Ever since they diagnosed me, I have always had my doctor
here. Not too long ago I moved to [city name redacted], and
they put that I should go to another hospital. They sent to say
that I need to go to another hospital and no. Because it’s like,
to begin the story all over again, and not all hospitals have the
same information. That’s why yesterday when the doctor
kept saying, ‘Why don’t you go [get care] closer to where you
live?’ I told her no because in other hospitals they don’t have
my [medical] record.”
—Hispanic woman, 55, documented
Undocumented Patients Describe Distinct ED Care-Seeking Processes
Experiencing Difficulty Seeking Ambulatory Care. All patients interviewed were asked if
they considered seeking ambulatory care (e.g., primary care, urgent care, or specialty care)
prior to seeking ED care. Unlike documented participants, undocumented participants
described the unique phenomenon of experiencing difficulties seeking ambulatory care prior to
ED care. Though some undocumented participants shared their experiences of seeking specialty
care prior to ED care, most described their attempts to access care at CHCs. Generally,
undocumented participants who were empaneled did not describe difficulties with accessing
ambulatory care. Undocumented participants who were not empaneled, however, shared
mixed perceptions of local ambulatory care services, particularly of CHCs. Participants with
positive perceptions of CHCs described them as their normal source of care and preferred the
convenience of scheduled appointments and shorter wait times to ED utilization. Positive
perceptions of CHCs were influenced by previous positive care-seeking experiences and friendly
interactions with clinic providers. Negative perceptions of CHCs were influenced by previous

44
negative care-seeking experiences, including difficulties with scheduling, costly care, dismissive
providers, and lack of symptom resolution. Undocumented participants’ perceptions of
ambulatory care services, particularly CHCs, influenced their decision to seek ED care.
Undocumented participants who did not attempt to seek care at a CHC prior to ED care
described being discouraged due to financial limitations and perceiving that CHCs would lack
the necessary equipment and specialty care needed to resolve their symptoms. Undocumented
participants who did attempt to seek CHC care described being motivated to do so as a
continuation of ongoing care.
Undocumented participants who sought CHC care described both successful and
unsuccessful care-seeking attempts. Successful care-seeking attempts were characterized by
receiving an appointment, receiving treatment for symptoms, being examined by a CHC
provider, and being prescribed medications prior to seeking ED care. Participants who received
CHC care described being sent home to monitor their symptoms following their visit.
Participants also described being instructed to seek ED care if their symptoms worsened or did
not resolve following treatment by a CHC provider. Others were prompted to seek ED care on
their own after symptoms worsened or remained unresolved following their CHC visit.
Unsuccessful attempts to seek CHC care were characterized by difficulties with scheduling, long
wait times, and understaffing. Undocumented participants who attempted but were not able to
receive CHC care experienced scheduling difficulties, sometimes having to wait days or weeks
to secure an appointment. In some cases, participants were unable to wait until their scheduled
appointment date due to worsening symptoms and chose to seek ED care instead. Other
participants described successfully obtaining an appointment at a CHC and arriving for care,

45
only to be told a provider was not available, leaving the participant with no choice but to go
home to wait out their symptoms before ultimately seeking ED care. Finally, some
undocumented participants described being prompted to seek ED care during ambulatory care
visits (e.g., CHC, urgent care, or specialty care) when providers determined their symptoms
warranted ED care or that the care facility lacked the necessary specialty care or equipment to
adequately treat their symptoms.
Seeking Greater Care Access and Tolerant Providers. Undocumented participants who
did not attempt to seek ambulatory care prior to ED care described having little to no choice
but to seek ED care to avoid high out-of-pocket costs and to maximize care and equipment
access. Participants shared that their inability to access comprehensive health insurance as a
result of their documentation status caused additional financial stress when deciding where to
seek care when experiencing health needs. Undocumented participants perceived safety-net
EDs to be a cost-effective option due to the financial support and services offered to uninsured
patients such as Emergency Medi-Cal. Participants described intentionally seeking ED care to
utilize the financial support and services offered to uninsured patients experiencing medical
emergencies. By utilizing ED services instead of ambulatory care, undocumented participants
attempted to minimize health-related financial stress.
When deciding where to seek care, undocumented participants preferred to seek ED
care over ambulatory care to maximize their access to comprehensive care. Perceptions of care
access were influenced by previous care-seeking experiences. Participants referred to their
personal experiences seeking care, or the experiences of members of their support system,
when assessing perceptions of care access. Participants considered provider bedside manner

46
and thoroughness (e.g., obtaining a detailed health history), available equipment and
technology, and anticipated health outcomes (e.g., resolution of their symptoms) when
assessing perceptions of care access. Participants perceived EDs to offer greater access to
advanced technology and equipment and thorough providers as compared to ambulatory care
services available to them, including CHCs.
Furthermore, when deciding where to seek ED care, undocumented participants
described preferring to visit facilities where they perceived they would be treated equitably,
regardless of their documentation status. Participants described preferring to seek safety-net
ED care because they knew they could not be denied services based on their insurance or
documentation status. Undocumented participants intentionally sought ED care at facilities
where they believed they could avoid xenophobia and discrimination based on their
documentation status. Some participants reflected on their previous experiences of
discrimination or stigma when seeking health care, which influenced their decision of where to
seek ED care. Participants preferred to visit EDs where they anticipated interacting with
tolerant providers and receiving comprehensive health care, regardless of their documentation
status. Table 6 presents themes and supportive quotes related to undocumented participants’
unique ED care-seeking processes described above.
Table 6. Themes and Supportive Quotes of Undocumented Participants’ Unique Safety-Net ED
Care-Seeking Processes
Themes Supportive quotes
Experiences in
attempting to
seek CHC care
Receiving care at a CHC
“Before coming, I called to make an appointment but since there weren’t
any [appointments] available, they gave me one for the following
Tuesday. I went and they gave me lab exams and everything. When the
doctor saw me she was the one who referred me over here [to the ED].

47
She immediately gave me the paper so that I could come here [to the
ED].”
—Hispanic woman, 41, undocumented
“At first, I didn’t think to come in because I was already getting a
treatment. The clinic that I go to prescribed me something and
emphasized that if I didn’t see my wound healing, that I go to the
emergency department. That’s why I decided to come here [to the ED]. I
spent four days at home, drinking the medication they prescribed me
and waiting for my wound to heal or form a scar, but I noticed I wasn’t
getting better and decided to come [to the ED] once and for all. I knew it
was going take a long time [to be seen], and maybe that’s also why I
didn’t really want to come . . .”
—Hispanic man, 54, undocumented
Not receiving care at a CHC
“After I told her I had fallen, the doctor told me, ‘We are going to send
you to the emergency department.’ From the beginning she’s always told
me, ‘If you fall, do not wait, go to the emergency department right away.
You don’t have to wait to see if anything changes.’”
—Hispanic woman, 72, undocumented
“Yesterday I went to the clinic where I normally go, but they couldn’t
attend to me. I waited about 40 minutes before they let me know that
the doctor had not come in. I went back to my house waiting to feel a
little better, but it was all the contrary. I woke up at four in the morning,
presented myself at work, but I couldn’t do it. I went back to my house,
felt worse, and opted to come here [to the ED].”
—Hispanic man, 60, undocumented
“The other place I went to wouldn’t take me because I didn’t have a
COVID-19 vaccination card. God knows where that card ended up . . .
They told me, ‘Go to the general hospital, they’ll likely cut off your foot,’
and well, here we are. Everything is bigger here; the name says it all,
right?”
—Hispanic man, 48, undocumented
Choosing where
to seek ED care
Seeking better care access
“This is the place where they [the doctors] are going to serve us
[undocumented patients] better than some clinic. If I go to the clinic that
I normally go to, they don’t have either the specialties or the gadgets
that they have here [at the ED]. That’s why I chose to come here because
I knew I was very sick, and where better to go than here [the ED], where I
could be served better than in another part?”
—Hispanic man, 60, undocumented

48
“I have been here [to the ED] before. There are other places [hospitals
and clinics] that now, with the pandemic, they don’t even want to
receive you. They [other hospitals and clinics] just check you and give you
medicine; that happened to my boyfriend. They checked him; they gave
him antibiotics; and they gave him pills. He was getting worse, so that’s
when I told him, ‘Come to [hospital name redacted],’ and here’s where
they helped him. I have been here before, and I know that it’s one of the
hospitals that has more equipment and services.”
—Hispanic woman, 48, undocumented
“We [undocumented patients] don’t have health insurance, so we need
to go to the emergency department. The only thing we have is our
emergency services, nothing more. It’s the only thing we have.”
—Hispanic man, 39, undocumented
“Honestly, we [undocumented patients] know that it is the emergency
department, and we [undocumented patients] do not have to pay for
anything. The emergency paper that they [the doctors] give us
[undocumented patients] helps us [undocumented patients] not get
charged. We [undocumented patients] don’t have enough money to pay
a private clinic, which is super expensive. Therefore, coming here [the
emergency department] is what helps us [undocumented patients].”
—Hispanic man, 39, undocumented
“I don’t have Medicaid. They [EMS] told me they couldn’t bring me to any
other hospital but this one.”
—Hispanic woman, 43, undocumented
Seeking tolerant providers
“There are doctors that you notice are not interested in whether you do
or don’t have papers or that your status is legal or illegal. And it shows in
others—I am not talking about this hospital, but elsewhere—where you
can feel the harshness of when you are not fully taken into consideration.
I’ve suffered this before. I will never forget that feeling of rejection from
that past doctor . . . It makes [me] feel uncomfortable . . . I haven’t seen
them [the doctors] put care about the status of patients here, but in
other places [hospitals and clinics] I have.”
—Hispanic man, 60, undocumented
“We [undocumented patients] would like to have papers and be treated
the same. They don’t stop assisting us [undocumented patients] here [at
the emergency department] and, well, that’s grand. We should be
grateful because even though we don’t have papers, they [emergency
department providers] won’t stop attending [to] us. They [U.S.-born and

49
documented patients] have more privilege than us [undocumented
patients], but as I said, we have the joy of knowing that even though we
don’t have papers, well, they [emergency department providers] can’t
deny us [undocumented patients] services here [in the ED], but I know
that the people who do have papers have more privileges.”
—Hispanic woman, 48, undocumented
Summary of the Model
The decision-making process of seeking ED care is complicated and influenced by
multiple factors. Patients we interviewed described the process of noticing symptoms, delaying
ED care, prompting ED care, and choosing where to seek ED care prior to seeking ED care.
Participants who delayed ED care-seeking described doing so to avoid inconveniences
associated with ED care-seeking such as long wait times and anticipated provider judgment,
and coped with symptoms by self-treating or self-medicating. Participants were prompted to
seek ED care when they perceived their symptoms to be life threatening or unmanageable,
worsening or unresolved, or when prompted by others such as friends, family, and ambulatory
care providers. Participants described reflecting on their previous positive care-seeking
experiences and assessing convenience such as empanelment and proximity when deciding
where to seek ED care.
Additionally, undocumented participants described emergency care-seeking processes
distinct from those of their documented counterparts. Undocumented participants who
delayed ED care-seeking often did so by first seeking other forms of care, particularly
ambulatory care at CHCs. Undocumented participants described being prompted to seek ED
care following failed attempts to seek ambulatory care and when referred by ambulatory care
providers. Undocumented participants also described seeking tolerant providers and greater

50
access to specialty care and equipment when deciding where to seek ED care. Figure 3 presents
our theory of the safety-net emergency care-seeking process as described by documented and
undocumented participants.
Figure 3. Theory of the Safety-Net Emergency-Care-Seeking Process as Described by
Documented and Undocumented Participants
Discussion
Previous research has examined how patients’ emergency care-seeking processes are
influenced by disease-related anxiety, prior patterns of health-seeking behavior, feelings of
safety and familiarity with the hospital setting, and difficulties accessing CHC services (Henson
et al., 2016). Similarly, other studies have used a grounded theory approach to develop theories
of care-seeking among ED patients (Lutz et al., 2018). Most of these studies, however, were not
conducted in the safety-net setting nor did they consider the role of documentation status as
an influence on ED care-seeking behaviors. Our findings enhance the developing literature that
conceptualizes patients’ processes and reasons for seeking safety-net ED care (Kangovi et al.,
2013; Lutz et al., 2018; Pines et al., 2016; Rising et al., 2016; Uscher-Pines et al., 2013). Like
previous studies, our study found that safety-net ED care-seeking was influenced by a range of
factors, including perceived symptom severity, convenience, previous health care experiences,
social support, and referral or advice. Our findings further support the existing literature by

51
presenting how safety-net patients’ ED care-seeking processes were influenced by perceptions
of symptom severity and manageability and previous care-seeking experiences. Ultimately, we
found that safety-net patients experienced similar emergency care-seeking processes to those
in non-safety-net settings. Furthermore, we found that for the most part, documented and
undocumented patients experienced similar safety-net ED care-seeking processes.
Safety-net scholars have highlighted distinct and intersecting barriers to ambulatory
care experienced by undocumented immigrants, including exclusionary policies and practices
(Balakrishnan & Jordan, 2019). However, most studies investigating barriers to ambulatory care
among undocumented immigrants have gathered safety-net providers’ and health care
workers’ perspectives, rather than those of undocumented patients (Kaki et al., 2022; OrnelasDorian et al., 2021). Our study addresses existing gaps in the literature by prioritizing
undocumented patients’ perspectives and experiences related to ED care-seeking. By
investigating the emergency care-seeking processes of undocumented safety-net patients in
Los Angeles County, home to one of the nation’s largest undocumented patient populations,
our study adds to the understanding of the unique barriers to care experienced by this
understudied and historically marginalized patient population. Like previous studies, our study
found that as a result of exclusionary policies that limit access to comprehensive health
insurance, undocumented immigrants experience additional barriers to ambulatory care access,
which ultimately influences their decision to seek ED care. Our study found that when
undocumented immigrants attempted to bridge gaps in ambulatory care access by seeking care
at CHCs, they encountered scheduling difficulties, understaffing, unresolved symptoms, and
costly care. Though undocumented patients preferred the convenience of scheduled

52
appointments and short wait times that ambulatory care offers, they described being left with
no choice but to seek ED care when ambulatory care services, particularly CHCs, could not meet
their needs.
Existing gaps in care coverage among undocumented immigrants, which limit their
access to ambulatory care, were exacerbated by their exclusion from the ACA. Presently,
undocumented patients are limited in their ability to access comprehensive care as a result of
their limited ability to obtain or purchase health insurance. Without access to comprehensive
health insurance, undocumented immigrants are left with little to no choice but to rely on
safety-net services, including EDs, when experiencing health needs. Throughout the U.S., local
and state programs have been developed to reduce gaps in access to comprehensive care
coverage experienced by undocumented immigrants. In Los Angeles County, home to one of
the largest populations of undocumented immigrants in the country, My Health LA—a program
that offers free-to-low-cost primary care to uninsured and low-income residents—was
developed in 2014 through the Department of Health Services (LAC-DHS). Previous studies have
reported that despite primary care services being readily available through My Health LA, they
remain underutilized by undocumented residents of Los Angeles County (Yu et al., 2020).
Reasons for underutilization of these services discussed in previous studies include fear,
misinformation, and misperceptions of coverage and immigration policies, particularly
throughout the 2020 election cycle. These previous findings led to the work of identifying and
conceptualizing gaps in health care offerings available to versus utilized by undocumented
immigrants residing in Los Angeles County.

53
Our findings build on the previous literature by furthering our understanding of the
ways in which ambulatory care utilization, particularly at CHCs, is more complicated and
nuanced than is currently described in the literature. The undocumented immigrants we
interviewed were aware of the existing programs aimed at reducing gaps in ambulatory care
access, such as My Health LA’s CHCs, but they described reasons for both attempting and not
attempting to receive care at CHCs prior to seeking ED care. Reasons for engaging CHC care
included hoping to avoid a visit to the ED, trust in providers, and continuity of care. Reasons for
not engaging CHC care included little faith in ambulatory care facilities’ ability to resolve
symptoms due to lack of necessary equipment and specialty care, scheduling difficulties, and
financial limitations. Our findings indicate that undocumented immigrants do attempt to utilize
existing ambulatory care service offerings in Los Angeles County, particularly CHCs, but
experience difficulties when doing so. More research is needed to further our understanding of
how existing ambulatory care options, especially CHCs, can be improved to better address the
needs of uninsured patients. Our findings indicate that existing programs aimed at reducing
gaps in ambulatory care access experienced by uninsured patients, including undocumented
immigrants, are a good starting point and could benefit from engaging members of the
community in discussions and research to improve engagement, quality, and access.
Limitations
This framework is based on the experiences of 25 participants who sought ED care at a
safety-net hospital in Los Angeles County. Future studies should be conducted in other EDs
throughout the country to determine transferability of findings. There may also be subjective
bias in the methods of this study, particularly during the coding process. However, study

54
personnel attempted to mitigate this potential limitation through the implementation of ICR
scoring and use of multiple coders. The study codebook was not considered finalized until
coders achieved an ICR score of 85% or greater agreeability.
Despite its limitations, this study also holds several strengths. The systematic and
iterative process fundamental to grounded theory research sets it apart from other descriptive
forms of qualitative data analysis. Grounded theory is favored for exploratory qualitative
research studies as a result of its ability to incorporate the use of multiple types of data,
provide an in-depth perspective into individual experiences, and build new, purposeful,
systematic generation of theories from coding of data (Glaser, 1992; Glaser & Strauss, 2017;
Strauss & Corbin, 1994). Moreover, we prioritized the experiences of patients who sought
safety-net ED care, a population underrepresented in the literature. In addition, undocumented
immigrants, a historically marginalized and understudied population, comprised more than a
third of our study sample. Study findings further contribute to the literature by providing a
more comprehensive understanding of ED care-seeking behaviors among documented and
undocumented adult safety-net patients.
Summary
As described previously, we used a sequential mixed-methods approach to examine the
association between documentation status and safety-net ED care-seeking at the largest safetynet hospital in Los Angeles. We developed a theoretical framework that describes emergency
care-seeking processes as described by a sample of safety-net patients we interviewed (n=25)
and highlighted the distinct processes described by undocumented participants (study 1). Using
a grounded theory approach, we described undocumented patients’ unique barriers to

55
ambulatory care-seeking such as scheduling difficulties, high costs of care, and underresourced
facilities, which influenced their decisions to seek safety-net ED care. These unique barriers
were not described among U.S.-born or foreign-born documented patients. Throughout the
iterative process, we determined that documentation status influences ambulatory care access
and safety-net ED utilization. However, the extent to which documentation status influences ED
utilization for ACSCs remained unclear. To investigate the association between documentation
status and ED visit for an ACSC, an age-stratified multivariate logistic regression in a sample of
n=129,834 safety-net patients was conducted in the subsequent chapter (study 2). Informed by
the theoretical framework described above, it was hypothesized that undocumented safety-net
patients would have higher odds of ED utilization for an ACSC compared to U.S.-born patients.
Conflicts of Interest
None to report.
Funding
Agency for Healthcare Research and Quality Dissertation Award Recipient (R36).
Acknowledgments
The authors would like to thank the various medical and undergraduate students who
assisted with transcribing and translating the interview audio-files used for this analysis. We
appreciate your contribution to this work. We would also like to thank the staff, nurses, and
physicians who provided feedback and support during the data collection phase of this project.
Finally, and most importantly, we would like to express immense gratitude to our study
participants. Thank you for inviting us into your lives and trusting us with your stories. None of
this would have been possible without you.

56
Chapter 3: The Association between Patients’ Documentation Status and Emergency
Department Visit for an Ambulatory Care Sensitive Condition (ACSC) in an Urban Safety-Net
Hospital in Los Angeles: A Cross-Sectional Study
Study Objective
The goal of this study was to investigate the association between documentation status
and use of safety-net ED for an ACSC. We were particularly interested in the association
between safety-net ED visit for an ACSC among undocumented patients compared to U.S.-born
patients. We hypothesized that ED utilization for an ACSC would be higher among foreign-born
undocumented safety-net patients compared to U.S.-born patients.
Background
ACSCs are conditions for which good outpatient care can potentially prevent the need
for hospitalization. Due to distinct limitations in comprehensive health insurance access
experienced by foreign-born undocumented immigrants, this population may be at a greater
risk for safety-net ED visits for an ACSC compared to U.S.-born patients.
Methods
We conducted a cross-sectional study using claims and EHR data from 2016 to 2019 at
Los Angeles Department of Health Services’ (LADHS) largest public hospital. Using multivariate
logistic regression, we examined the association between documentation status and ED visit for
an ACSC among all Los Angeles County residents who had an ED visit at the largest Level I
trauma center in Los Angeles. Models were stratified by age (age categories: <25 years, 26–64
years, >65 years) and adjusted for differences in sex, insurance, race, ethnicity, and
comorbidity. We used unique patient identifiers, including country of birth, Social Security
number, and insurance type to classify participants’ documentation status.

57
Results
In a sample of n=129,834 safety-net patients, we found that foreign-born
undocumented patients between the ages of 26 and 64 years old have 1.3 higher odds of ED
use for an ACSC compared to U.S.-born patients after adjusting for covariates. We did not find a
statistically significant association between documentation status and ED visit for an ACSC
among participants aged 25 years younger and those 65 years and older.
Conclusions
Our study found that undocumented patients aged 26 to 64 have higher odds of ED
utilization for an ACSC compared to U.S.-born patients. Our results suggest more work is
needed to connect undocumented patients with quality ambulatory care to prevent avoidable
safety-net ED visits for an ACSC. Recent literature suggests undocumented immigrants
experience unique barriers to ambulatory care, specifically primary care, such as lack of timely
appointments, cost of care, fear of discovery and deportation, misinformation, and
misperceptions of coverage and immigration policies. Sanctuary cities such as Los Angeles have
developed programs to try to address gaps in ambulatory care access experienced by
uninsured, undocumented patients. However, studies have shown that these resources are
underutilized. More research is needed to understand barriers, improve quality, and increase
utilization of ambulatory care services among undocumented safety-net patients.

58
Introduction
Undocumented immigrants are underrepresented in health behavior and health service
utilization research. Most large studies investigating facilitators and barriers to health care
access in the safety-net setting do not differentiate by documentation status (Shi et al., 2017).
One of the potential reasons for the lack of representation of undocumented patients in health
services research may be due to challenges in identifying undocumented patients in medical
records. EHRs offer a unique opportunity to determine immigration status and address gaps in
the existing health utilization literature among immigrant patient populations. Studies that
have utilized EHRs to approximate immigration status have had favorable results and accuracy,
particularly when using health insurance, Social Security number, or country of birth data
(Heintzman et al., 2020; Ross et al., 2017). More studies are needed to inform this approach,
particularly in the safety-net setting and in locations with large and diverse foreign-born
undocumented patient populations such as Los Angeles.
ACSCs are “conditions for which good outpatient care can potentially prevent the need
for hospitalization, or for which early intervention can prevent complications or more severe
disease” (Agency for Healthcare Research and Quality, 2021). ACSCs are “intended to reflect
issues of access to, and quality of, ambulatory care in a given geographic area”(Agency for
Healthcare Research and Quality, 2021). Hospitalizations for conditions such as uncontrolled
diabetes, COPD, asthma, heart failure, urinary tract infections, community-acquired
pneumonia, and hypertension are all considered potentially preventable with adequate access
to ambulatory care. Studies have found that ED use for ACSCs is costly and may have negative
consequences on safety-net patients, caregivers, and care providers, which negatively impacts

59
patient outcomes (Cervantes et al., 2020; Donoho et al., 2018; Erickson et al., 2020). Identifying
high-risk populations for safety-net ED utilization for ACSCs is critical for reducing ED
overcrowding and improving health care quality and outcomes for patients and providers.
Little is known about undocumented patients’ ED use for ACSCs. Due in part to
exclusionary policies that limit access to comprehensive health insurance, undocumented
immigrants may be at a greater risk for developing certain ACSCs as compared to their U.S.-
born counterparts (Balakrishnan & Jordan, 2019; Molina et al., 2015; Palazzolo et al., 2016).
Undocumented patients have been found to be at greater risk for experiencing barriers to
primary care access compared to U.S.-born patients (Ku & Matani, 2001; Martinez et al., 2015;
Ortega et al., 2007). However, it is unclear whether increased risk for ACSCs and barriers to
ambulatory care services results in increased ED utilization for ACSCs among undocumented
immigrants. More studies that investigate the association between documentation status and
ED utilization for ACSCs in the safety-net setting are needed (Balakrishnan & Jordan, 2019).
Goals of This Investigation
The goal of this investigation was to examine the association between documentation
status and use of safety-net ED for an ACSC. We were particularly interested in the association
between safety-net ED visit for an ACSC among undocumented patients compared to U.S.-born
patients. We hypothesized that ED utilization for an ACSC would be higher among foreign-born
undocumented safety-net patients compared to U.S.-born patients.
Methods
Data Sources

60
We identified all patients who had an ED visit from 2016 to 2019 in LADHS’s largest
public hospital and Level I trauma center, which primarily serves residents in Los Angeles. The
data include services provided, visit disposition, patient identifiers (medical record number,
address, et cetera), discharge diagnosis codes, hospital site, principal payer for the visit, and
patient demographics. Patient self-reported demographics include race, ethnicity, gender, age,
country of birth, primary language spoken, zip code of residence, and presence or absence of a
Social Security number.
Our analytic sample to study emergency care utilization was composed of patients who
received their ED care at the hospital of interest between January 2016 and December 2019,
whose zip code pertains to the county of Los Angeles, and who were 18 years of age or older
during the study period. Patients’ data were aggregated and analyzed at the person level,
where all patients’ data were summarized to produce one record per person. Given that
documentation status was our primary predictor of interest, patients with discrepancies in their
documentation status categorization throughout the study period were excluded from the
analysis.
Measures
Documentation Status. Documentation status classifications were approximated using
patients’ country of birth, insurance type, and presence or absence of Social Security number
data. Country of birth data was consolidated to create a three-category variable (response
items: U.S. born, foreign born, missing). We extracted patients’ insurance information from a
primary payer variable to create a seven-category insurance variable (response items:
Emergency/Restricted Scope Medi-Cal, Medicare, uninsured, Medicaid, other, presumptively

61
eligible for Medi-Cal, and private). Social Security number data was used to create a binary
indicator variable (response items: has Social Security number or no/missing Social Security
number). Patients’ country of birth, insurance, and Social Security number data were
aggregated to create a proximal three-category documentation status variable (response items:
U.S. born, foreign-born documented, foreign-born undocumented).
Patients who were born in the U.S. were classified as U.S. born; those who were born
outside the U.S. but who had a Social Security number or were comprehensively insured
through Medicaid or Medicare were classified as foreign-born documented; and those who
were born outside the U.S. and did not have a Social Security number or who were enrolled in
insurance programs allotted for undocumented individuals, including Emergency/Restricted
Medi-Cal, were classified as foreign-born undocumented. Classifications were checked for
consistency across visits by comparing baseline categorization (i.e., categorization at first visit)
to subsequent categorizations (i.e., categorization at subsequent visit[s]). Given that
documentation status was our primary predictor of interest, patients with discrepancies in their
documentation status categorization throughout the study period were excluded from the
analysis. Table 7 presents the insurance names, descriptions, and codes that were used to
create our categorical insurance variable. Figures 4–6 present visual classifications of
documentation status among U.S.-born, foreign-born documented, and foreign-born
undocumented patients, respectively.
Table 7. Insurance Names, Descriptions, and Codes Used to Create Seven-Category Insurance
Variable
Insurance names and descriptions Insurance codes Insurance category
MEDI-CAL RESTRICTED BENEFITS, MEDI-CAL
RESTRICTED BENEFITS NON COVERED 406, 403 Emergency/Restricted
Scope Medi-Cal

62
MEDICARE 301, MEDICARE HMO,
MEDICARE INPATIENT PART B BENEFITS
ONLY, KAISER MEDICARE MANAGED CARE,
LA CARE MEDICARE MANAGED CARE,
MEDICARE CAL OPTIMA
301, 311, 543, 544,
545, 636 Medicare
SELF PAY OUTPATIENT, PREPAYMENT
OUTPATIENT, SELF PAY INPATIENT,
UNKNOWN
000, 325, 469, 470 Uninsured
MEDICAID, MEDI-CAL, MEDI-CAL
CALIFORNIA CHILDREN’S SERVICES, MEDICAL MENTAL HEALTH,
MEDI-CAL CAL OPTIMA DIRECT, CALIFORNIA
CHILDREN’S SERVICES, MEDI-CAL CAL
OPTIMA PENDING, CALIFORNIA CHILDREN’S
SERVICES PENDING, MEDI-CAL PENDING AID
TO THE TOTAL DISABL, MEDI-CAL
MANAGED CARE LA CARE, MEDI-CAL
MANAGED CARE HEALTH CARE LA, MEDICAL MANAGED CARE LA CARE (DHS), MEDICAL MANAGED CARE HEALTH NET, MEDICAL MANAGED CARE HEALTH NET (DHS),
MEDI-CAL MANAGED CARE BLUE CROSS,
MEDI-CAL MANAGED CARE CARE FIRST,
MEDI-CAL MANAGED CARE MOLINA, MEDICAL MANAGED CARE HEALTH CARE PLAN,
MEDI-CAL MANAGED CARE KAISER, MEDICAL CAL OPTIMA
510, 405, 409, 427,
438, 381, 555, 380,
432, 651, 617, 644,
646, 615, 656, 666,
661, 564, 671, 550
Medicaid, including
Medi-Cal and Medi-Cal
Managed Care
PLAN OF PAYMENT, SHERIFF AND OTHER
AGENCIES, IN-HOME SUPPORT SERVICES
IHSS, ABILITY TO PAY WITH LIABILITY,
ABILITY TO PAY WITH NO LIABILITY,
MENTAL HEALTH, PROBATION
DEPARTMENT, OUT OF COUNTY COUNTRY,
STATE HOSPITAL REFERRAL, RETURNED
DATA MAILER BAD ADDRESS, OTHER
COUNTY DEPARTMENTS, CANCER
DETECTION PROGRAM, VETERANS AFFAIRS,
OUT OF COUNTY DISCOUNT PAYMENT
PLAN, GENERAL RELIEF, FAMILY PLANNING
NON MEDI-CAL, ASSAULT & ABUSE
EVIDENCE, MANDATED PROGRAMS/PUBLIC
HEALTH, MENTAL HEALTH WITH UMDAP
LIABILITY, ADMINISTRATIVE HOLD, FAST
478, 388, 441, 351,
350, 320, 387, 501,
464, 490, 384, 365,
508, 484, 352, 480,
373, 476, 321, 499,
539, 363, 358, 345,
360, 635, 383
Other

63
TRACK AGREEMENT, RESEARCH AND GRANT
PROGRAMS, GENETICALLY HANDICAPPED,
RYAN WHITE PENDING, RYAN WHITE
PROGRAM, LA CARE HEALTHY FAMILIES,
LAW ENFORCEMENT
HOSPITAL PRESUMPTIVE ELIGIBILITY (PE),
MEDI-CAL PENDING OTHER DISTRICT, MEDICAL PENDING DISTRICT (HOSPITAL DESI,
MEDI-CAL PENDING DED OUTPATIENT –
REFERR, MEDI-CAL PENDING DISTRICT
402, 423, 407, 425,
428
Presumptively eligible
for Medi-Cal
BLUE CROSS COMMERCIAL, KAISER
COMMERCIAL, PRIVATE INSURANCE, BLUE
SHIELD COMMERCIAL, HEALTH NET
COMMERCIAL, INDUSTRIAL ACCIDENT
WORKERS COMPENSATION, UNITED
HEALTH CARE COMMERCIAL, AETNA
COMMERCIAL, INDUSTRIAL ACCIDENT
COUNTY EMPLOYEES, CIGNA COMMERCIAL,
TRICARE, INSURANCE MED PAY MEDICAL
COVERAGE, EMPIRE BLUE CROSS SHIELD,
PPO AFFORDABLE HEALTH CONCEPTS,
ACCIDENT LITIGATION, PACIFICARE
COMMERCIAL
504, 551, 531, 583,
581, 511, 523, 524,
536, 525, 503, 533,
526, 577, 461, 530
Private
Figure 4. Categorization of U.S.-Born Patients

64
Figure 5. Categorization of Likely-Documented Patients Using Country of Birth, Social Security
Number, and Insurance Type Data
Figure 6. Categorization of Likely-Undocumented Patients Using Country of Birth, Social
Security Number, and Insurance Type Data
Ambulatory Care Sensitive Conditions. In accordance with AHRQ PQIs protocol, we
reviewed patients’ discharge diagnosis codes for the presence of ICD-10-CM codes pertaining to
any one of the following nine ACSCs: diabetes, short-term complications; diabetes, long-term
complications; COPD or asthma in older adults; hypertension; community-acquired pneumonia;

65
urinary tract infection; uncontrolled diabetes; and asthma in younger adults. We created a
binary outcome variable to reflect patients’ ACSC status. If participants had any ED visits with
discharge diagnosis code(s) pertaining to an ACSC throughout the study period, they were
classified as having at least one ED visit for an ACSC. Patients with no discharge diagnosis codes
pertaining to an ACSC throughout the study period were classified as having no ED visits for an
ACSC. Table 8 presents a full list of ACSCs and their corresponding ICD-10-CM codes used in this
analysis.
Table 8. AHRQ’s List of ACSCs and Their Corresponding ICD-10-CM Diagnosis Codes
ACSC description ICD-10-CM diagnosis codes corresponding to ACSC
Diabetes, shortterm
complications
E1010, E1011, E10641, E1100, E1101, E1110, E1111, E11641
Diabetes, longterm
complications
E1021, E1022, E1029, E10311, E10319, E10321, E103211, E103212,
E103213, E103219, E10329, E103291, E103292, E103293, E103299,
E1121, E1122, E1129, E11311, E11319, E11321, E113211, E113212,
E113213, E113219, E11329, E113291, E113292, E113293, E113299,
E10331, E103311, E103312, E103313, E103319, E10339, E103391,
E103392, E103393, E103399, E10341, E103411, E11331, E113311,
E113312, E113313, E113319, E11339, E113391, E113392, E113393,
E113399, E11341, E113411, E103412, E103413, E103419, E10349,
E103491, E103492, E10349, E103499, E10351, E103511, E103512,
E103513, E103519, E103521, E113412, E113413, E113419, E11349,
E113491, E113492, E113493, E113499, E11351, E113511, E113512,
E113513, E113519, E113521, E103522, E103523, E103529, E103531,
E103532, E103533, E103539, E103541, E103542, E103543, E113522,
E113523, E113529, E113531, E113532, E113533, E113539, E113541,
E113542, E113543, E103549, E103551, E103552, E103553, E103559,
E10359, E103591, E103592, E103593, E103599, E1036, E1037X1,
E1037X2, E1037X3, E113549, E113551, E113552, E113553, E113559,
E11359, E113591, E113592, E113593, E113599, E1136, E1137X1,
E1137X2, E1137X3, E1037X9, E1039, E1040, E1041, E1042, E1043, E1044,
E1049, E1051, E1052, E1059, E10610, E10618, E10620, E10621, E10622,
E10628, E10630, E10638, E1069, E108, E1137X9, E1139, E1140, E1141,
E1142, E1143, E1144, E1149, E1151, E1152, E1159, E11610, E11618,
E11620, E11621, E11622, E11628, E11630, E11638, E1169, E118

66
COPD or asthma
in older adults
J410, J411, J418, J42, J430, J431, J432, J438, J439, J440, J441, J449, J470,
J471, J479
Hypertension I10, I119, I129, I1310, I160, I161, I169
Heart failure
I0981, I110, I130, I132, I501, I5020, I5021, I5022, I5023, I5030, I5031,
I5032, I5033, I5040, I5041, I5042, I5043, I50810, I50811, I50812, I50813,
I50814, I5082, I5083, I5084, I5089, I509
Communityacquired
pneumonia
J13, J14, J15211, J15212, J153, J154, J157, J159, J160, J168, J180, J181,
J188, J189
Urinary tract
infection
N10, N12, N151, N159, N16, N2884, N2885, N2886, N3000, N3001,
N3090, N3091, N390
Uncontrolled
diabetes E10649, E1065, E11649, E1165
Asthma in
younger adults
J4521, J4522, J4531, J4532, J4541, J4542, J4551, J4552, J45901, J45902,
J45990, J45991, J45998
Covariates. We adjusted for the following covariates: age (response items: <25 years,
26–64 years, >65 years); sex (response items: woman or man); race and ethnicity (response
items: White, Hispanic, Asian, Black, and other); and a modified Charlson Comorbidity Index
(CCI) (response items: none, mild, moderate, severe) (Glasheen et al., 2019). We created a
modified version of the original CCI to adjust for mortality risk and expected health care
resource consumption in our model. To create CCI scores, we reviewed patients’ discharge
diagnosis codes for the presence of ICD-10-CM codes pertaining to any one of the following 15
conditions: myocardial infarction (including acute myocardial infarction and history of
myocardial infarction), peripheral vascular disease, cerebrovascular disease, dementia, paralysis
(hemiplegia or paraplegia), renal disease (mild to moderate), liver disease (mild), liver disease
(moderate to severe), peptic ulcer disease, rheumatologic disease, HIV, AIDS, any malignancy
(including lymphoma and leukemia, except malignant neoplasm of skin), metastatic solid
tumor, and renal disease (severe). Conditions that appeared on the list of AHRQ PQIs and CCIs

67
were not included in the modified CCI, including congestive heart failure, chronic pulmonary
disease, diabetes without chronic complications, and diabetes with chronic complications. We
created a binary indicator variable for each comorbid condition where patients were classified
as having a particular comorbid condition if they had any discharge diagnosis code(s) pertaining
to a specific comorbid condition throughout the study period. Weights for each comorbid
condition, where higher scores indicate higher severity, were applied and summarized for each
patient, as suggested in the literature (Glasheen et al., 2019; Quan et al., 2011). Patients’
overall CCI scores were sorted into a four-category variable (response items: none, mild,
moderate, severe). Patients with CCI scores of zero were classified as having no comorbidities;
those with CCI scores of 1–2, mild comorbidities; CCI scores of 3–4, moderate comorbidities;
and CCI scores greater than or equal to 5, severe comorbidities, as is custom in the literature
(Glasheen et al., 2019; Quan et al., 2011). Table 9 provides a list of the conditions, weights, and
corresponding diagnosis codes that were used to create our modified CCI.
Table 9. Conditions, Weights, and Corresponding Diagnosis Codes Used to Create Modified
CCI
Condition Weight Corresponding diagnostic codes
Myocardial infarction, including
acute myocardial infarction and
history of myocardial infarction
1 I21, I22, I252, I099, I255, I420,
I425, I426, I427, I428, I429, I43,
I50, P290
Peripheral vascular disease 1 I70, I71, I731, I738, I739, I771,
I790, I791, I792, I798, K551, K558,
K559, Z958, Z959
Cerebrovascular disease 1 G45, G46, H340, H341, H342, I60,
I61, I62, I63, I64, I65, I66, I67, I68,
I69
Dementia 1 F00, F01, F02, F03, F04, F05, F051,
F061, F068, G30, G132, G138, G30,
G310, G311, G312, G914, G94,
R4181, R54

68
Paralysis (hemiplegia or paraplegia) 2 G041, G114, G800, G801, G802,
G81, G82, G83, G830, G831, G832,
G833, G834, G839
Renal disease (mild to moderate) 1 I120, I129, I130, I131, N03, N032,
N033, N034, N035, N036, N037,
N05, N052, N053, N054, N055,
N056, N057, N18, N181, N182,
N183, N184, N189, N19, N250,
Z490, Z491, Z492, Z940, Z992
Liver disease (mild) 1 B18, K700, K701, K702, K703,
K709, K713, K714, K715, K717,
K73, K74, K760, K762, K763, K764,
K768, K769, Z944
Liver disease (moderate to severe) 3 I850, I859, I864, I982, K704, K711,
K721, K729, K765, K766, K767
Peptic ulcer disease 1 K25, K26, K27, K28
Rheumatologic disease 1 M05, M06, M315, M32, M33,
M34, M351, M353, M360
HIV 3 B20, B21, B22, B24
AIDS 6 B37, C53, B38, B45, A072, B25,
G934, B00, B39, A073, C46, C81,
C82, C83, C84, C85, C86, C87, C88,
C89, C90, C91, C92, C93, C94, C95,
C96, A31, A15, A16, A17, A18,
A19, B59, Z8701, A812, A021, B58,
R64
Any malignancy, including
lymphoma and leukemia, except
malignant neoplasm of skin
2 C00, C01, C02, C03, C04, C05, C06,
C07, C08, C09, C10, C11, C12, C13,
C14, C15, C16, C17, C18, C19, C20,
C21, C22, C23, C24, C25, C26, C30,
C31, C32, C33, C34, C37, C38, C39,
C40, C41, C43, C45, C46, C47, C48,
C49, C50, C51, C52, C53, C54, C55,
C56, C57, C58, C60, C61, C62, C63,
C64, C65, C66, C67, C68, C69, C70,
C71, C72, C73, C74, C75, C76,
C801, C81, C82, C83, C84, C85,
C88, C90, C91, C92, C93, C94, C95,
C96, C97
Metastatic solid tumor 6 C77, C78, C79, C800, C802
Renal disease (severe) 3 I120, I1311, I132, N185, N186,
N19, N250, Z49, Z992
Conditions that appeared on the list of AHRQ PQIs and CCIs were not included in the modified CCI,
including congestive heart failure, chronic pulmonary disease, diabetes without chronic complications,
and diabetes with chronic complications.

69
Data Analysis
To test the association between categorical variables, we used likelihood ratio and
global Wald tests. Before converting continuous variables into categorical values, we used
likelihood ratio tests to examine the hypothesis that multinomial parameterizations of
quantitative models provide a similar explanation of the data to the nominal model
(significance level p=0.05). We used multivariate logistic regression to examine the association
between documentation status and ED visit for an ACSC (having at least one ED visit for an
ACSC as the outcome variable). All covariates of interest were statistically significant in the
bivariate analysis and placed in a multivariate logistic regression model. We examined
correlation between factors in separate models using Pearson correlation coefficient test
statistics. We examined collinearity and multicollinearity between factors by examining
variance inflation factors (VIF). Variables that were strongly correlated (VIF > 5, Pearson
correlation coefficient > 0.5) were not included in the same model, such as age and
comorbidities. To examine potential confounding and effect modification, we included product
interaction terms in our model and compared effect estimates before and after adjustment.
Variables were treated as confounders if their measures of association changed by 10% or
greater after adjustment. We found no statistically significant product interaction terms. When
adding age to the model, the effect estimates of documentation status on ED visit for an ACSC
changed by 40% to 50%, indicating that age modifies the effect of documentation status on ED
visit for an ACSC. As a result, age was treated as a categorical variable and included as an effectmeasure modifier to investigate whether it modifies the association between documentation
status and ED visit for an ACSC. Age categories (response items: <25 years, 26–64 years, and

70
>65 years) were informed by health insurance age allowances where individuals younger than
26 years old qualify as health insurance dependents and eligible for full-scope Medi-Cal,
regardless of documentation status, and individuals 65 years or older qualify as Medicare
eligible. Statistical significance was determined at the =0.05 level. The final multivariable
logistic regression model predicted the adjusted odds ratios of ED visit for an ACSC adjusting for
other factors. Statistical analyses were conducted in STATA 17.0.
Results
Analytic Sample
Of the 179,203 patients who had all visits at our hospital of interest and a zip code
pertaining to Los Angeles, 21,106 were excluded for being younger than 18 years of age. An
additional 24,136 individuals’ visits occurred outside of the study period and were excluded. A
total of 2,459 individuals had discrepancies in their documentation status classification across
visits and were excluded. An additional 1,668 patients were missing diagnostic code and age
data and were excluded. Our final analytic sample was n=129,834. Figure 7 presents a flow
diagram of our inclusion criteria.

71
Figure 7. Inclusion Criteria and Development of Our Analytic Sample
Sample Characteristics by Documentation Status Classification
Of 129,834 patients who met our inclusion criteria, 32,780 (25%) had at least one ED
visit for an ACSC. Overall, 26,667 (21%) patients were insured through Emergency or Restricted
Medi-Cal, and 41,915 (32%) were insured through Medicaid. Mean age was 44.8 years.
Additionally, 17,106 (13%) patients were 25 years of age or younger, 97,091 (75%) patients
were ages 26 to 64, and 15,637 (12%) were 65 years or older. A total of 58,186 (45%) patients
were women, and 89,022 (69%) were Hispanic. Most patients (90%) did not have any comorbid
conditions. Using country of birth, Social Security number, and insurance data, we estimated
54,996 (42%) patients to be U.S. born, 28,126 (22%) to be foreign-born documented, and
46,712 (36%) to be foreign-born undocumented. Table 10 presents patient characteristics by
documentation status classification.

72
Table 10. Sample Characteristics by Documentation Status Classification
Documentation status
Characteristics
Total
(n=129,834)
U.S. born
(n=54,996)
Foreign-born
documented
(n=28,126)
Foreign-born
undocumented
(n=46,712)
Any ED visit for an ACSC
Yes 32,780
(25.25)
10,832
(19.70)
9,697
(34.48)
12,251
(26.23)
No 97,054
(74.75)
44,164
(80.30)
18,429
(65.52)
34,461
(73.77)
Presence of SSN
Yes 77,765
(59.90)
46,421
(84.41)
28,126
(100.00)
3,218
(6.89)
No/Missing 52,069
(40.10)
8,575
(15.59)
0
(0.00)
43,494
(93.11)
Country of birth
U.S. born 54,996
(42.36)
54,996
(100.00)
0
(0.00)
0
(0.00)
Foreign born 74,614
(57.47)
0
(0.00)
28,010
(99.59)
46,604
(99.77)
Missing 224
(0.17)
0
(0.00)
116
(0.41)
108
(0.23)
Insurance type
Emergency/Restricted
Medi-Cal
26,667
(20.54)
904
(1.64)
0
(0.00)
25,763
(55.15)
Medicare 9,726
(7.49)
4,106
(7.47)
5,165
(18.36)
455
(0.97)
Uninsured 11,191
(8.62)
4,601
(8.37)
2,427
(8.63)
4,163
(8.91)
Medicaid, incl.
Medi-Cal
41,915
(32.28)
26,208
(47.65)
12,629
(44.90)
3,078
(6.59)
Other, incl. govt
programs
12,340
(9.50)
8,744
(15.90)
1,795
(6.38)
1,801
(3.86)
Presumptive eligibility 19,520
(15.03)
5,742
(10.44)
3,754
(13.35)
10,024
(21.46)
Private 7,339
(5.65)
4,261
(7.75)
2,076
(7.38)
1,002
(2.15)
Missing 1,136
(0.87)
430
(0.78)
280
(1.00)
426
(0.91)
Age, years
Mean (SD) 44.84
(16.43)
39.05
(15.95)
54.29
(15.95)
45.97
(14.26)

73
<25 17,106
(13.18)
12,691
(23.08)
1,350
(4.80)
3,065
(6.56)
26–64 97,091
(74.78)
38,433
(69.88)
19,753
(70.23)
38,905
(83.29)
>65 15,637
(12.04)
3,872
(7.04)
7,023
(24.97)
4,742
(10.15)
Sex
Man 71,613
(55.16)
35,259
(64.11)
13,942
(49.57)
22,412
(47.98)
Woman 58,186
(44.82)
19,726
(35.87)
14,178
(50.41)
24,282
(51.98)
Missing 35
(0.03)
11
(0.02)
6
(0.02)
18
(0.04)
Race/ethnicity
Hispanic 89,022
(68.57)
27,712
(50.39)
19,728
(70.14)
41,582
(89.02)
Asian 6,067
(4.67)
863
(1.57)
3,520
(12.52)
1,684
(3.61)
Black 11,494
(8.85)
10,364
(18.85)
768
(2.73)
362
(0.77)
Other 9,057
(6.98)
6,491
(11.80)
1,639
(5.83)
927
(1.98)
White 5,928
(4.57)
4,656
(8.47)
814
(2.89)
458
(0.98)
Missing 8,266
(6.37)
4,910
(8.93)
1,657
(5.89)
1,699
(3.64)
CCI
None 116,196
(89.50)
50,568
(91.95)
24,036
(85.46)
41,592
(89.04)
Mild 9,107
(7.01)
2,894
(5.26)
2,807
(9.98)
3,406
(7.29)
Moderate 3,417
(2.63)
1,135
(2.06)
975
(3.47)
1,307
(2.80)
Severe 1,114
(0.86)
399
(0.73)
308
(1.10)
407
(0.87)
Data are reported as mean (SD) or n (%).
Abbreviations: ambulatory care sensitive condition (ACSC), confidence interval (CI),
emergency department (ED), odds ratio (OR).
*Percentage is out of 129,834 total individuals and 324,158 total ED visits.

74
Presence of Ambulatory Care Sensitive Conditions
Frequency of ED utilization for an ACSC differed across documentation status categories:
10,832 (20%) U.S.-born, 9,697 (35%) foreign-born documented, and 12,251 (26%) foreign-born
undocumented patients had at least one ED visit for an ACSC. Differences were also noted
across ACSC composite measures. Foreign-born documented and undocumented patients had a
higher frequency of acute, chronic, and diabetes-specific ACSCs compared to U.S.-born
patients. The most common conditions among nine ACSCs were hypertension (16%) and urinary
tract infection (6%). Foreign-born documented and undocumented patients had higher
frequencies of hypertension and urinary tract infections compared to U.S.-born patients.
Approximately 24% of foreign-born documented and 16% of foreign-born undocumented
patients had conditions of hypertension. Nearly 7% of foreign-born documented and more than
7% of foreign-born undocumented patients had conditions of urinary tract infections. Table 11
presents frequencies of ED utilization for ACSC composites and conditions by documentation
status.
Table 11. ASCS Frequencies and Composites
Documentation status
Type of ACSCs
Total
(n=129,834)
U.S. born
(n=54,996)
Foreign-born
documented
(n=28,126)
Foreign-born
undocumented
(n=46,712)
Composites
Overall
Yes 32,780
(25.25)
10,832
(19.70)
9,697
(34.48)
12,251
(26.23)
No 97,054
(74.75)
44,164
(80.30)
18,429
(65.52)
34,461
(73.77)
Acute
Yes 10,363
(7.98)
3,283
(5.97)
2,739
(9.74)
4,341
(9.29)

75
No 119,471
(92.02)
51,713
(94.03)
25,387
(90.26)
42,371
(90.71)
Chronic
Yes 26,875
(20.70)
8,833
(16.06)
8,359
(29.72)
9,683
(20.73)
No 102,959
(79.30)
46,163
(83.94)
19,767
(70.28)
37,029
(79.27)
Diabetes
Yes 6,519
(5.02)
1,659
(3.02)
1,943
(6.91)
2,917
(6.24)
No 123,315
(94.98)
53,337
(96.98)
26,183
(93.09)
43,795
(93.76)
Conditions
Diabetes
, short
-term
complications
Yes 477
(0.37)
212
(0.39)
90
(0.32)
175
(0.37)
No 129,357
(99.63)
54,784
(99.61)
28,036
(99.68)
46,537
(99.63)
Diabetes
, long
-term
complications
Yes 3,685
(2.84)
839
(1.53)
1,172
(4.17)
1,674
(3.58)
No 126,149
(97.16)
54,157
(98.47)
26,954
(95.83)
45,038
(96.42)
COPD or asthma in older
adults
Yes 1,659
(1.28)
1,061
(1.93)
338
(1.20)
260
(0.56)
No 128,175
(98.72)
53,935
(98.07)
27,788
(98.80)
46,452
(99.44)
Hypertension
Yes 20,917
(16.11)
6,407
(11.65)
6,876
(24.45)
7,634
(16.34)
No 108,917
(83.89)
48,589
(88.35)
21,250
(75.55)
39,078
(83.66)
Heart failure
Yes 3,695
(2.85)
1,482
(2.69)
1,093
(3.89)
1,120
(2.40)
No 126,139
(97.15)
53,514
(97.31)
27,033
(96.11)
45,592
(97.60)
Community
-acquired
pneumonia

76
Yes 3,422
(2.64)
1,300
(2.36)
946
(3.36)
1,176
(2.52)
No 126,412
(97.36)
53,696
(97.64)
27,180
(96.64)
45,536
(97.48)
Urinary tract infection
Yes 7,432
(5.72)
2,130
(3.87)
1,934
(6.88)
3,368
(7.21)
No 122,402
(94.28)
52,866
(96.13)
26,192
(93.12)
43,344
(92.79)
Uncontrolled diabetes
Yes 3,766
(2.90)
1,025
(1.86)
1,029
(3.66)
1,712
(3.67)
No 126,068
(97.10)
53,971
(98.14)
27,097
(96.34)
45,000
(96.33)
Asthma in younger adults
Yes 1,275
(0.98)
684
(1.24)
267
(0.95)
324
(0.69)
No 128,559
(99.02)
54,312
(98.76)
27,859
(99.05)
46,388
(99.31)
Data is reported as n (%).
Abbreviations: ambulatory care sensitive condition (ACSC); chronic obstructive pulmonary
disease (COPD).
Acute composite includes the following conditions: community-acquired pneumonia and
urinary tract infection.
Chronic composite includes the following conditions: diabetes, short-term complications;
diabetes, long-term complications; COPD; hypertension; heart failure; uncontrolled diabetes;
asthma.
Diabetes composite includes the following conditions: diabetes, short-term complications;
diabetes, long-term complications; uncontrolled diabetes.
*Percentage is out of 129,834 total individuals and 324,158 total ED visits.
Age Modifies the Effect of Documentation Status and ED Visit for an ACSC
Mean age among U.S.-born, foreign-born documented, and foreign-born undocumented
patients was 39.0, 54.3, and 46.0 years, respectively. Overall, 75% of the sample patients were
between the ages of 26 and 64. Table 12 presents sample characteristics by age category.

77
Table 12. Sample Characteristics by Age Category
Characteristics
Age group
Total
(n=129,834)
18–25 years
(n=17,106)
26–64 years
(n=97,091)
>65 years
(n=15,637)
Any ED visit for an ACSC
Yes 32,780
(25.25)
1,203
(7.03)
22,961
(23.65)
8,616
(55.10)
No 97,054
(74.75)
15,903
(92.97)
74,130
(76.35)
7,021
(44.90)
Documentation status
U.S. born 54,996
(42.36)
12,691
(74.19)
38,433
(39.58)
3,872
(24.76)
Foreign-born documented 28,126
(21.66)
1,350
(7.89)
19,753
(20.34)
7,023
(44.91)
Foreign-born undocumented 46,712
(35.98)
3,065
(17.92)
38,905
(40.07)
4,742
(30.33)
Presence of SSN
Yes 77,765
(59.90)
11,452
(66.95)
55,403
(57.06)
10,910
(69.77)
No/Missing 52,069
(40.10)
5,654
(33.05)
41,688
(42.94)
4,727
(30.23)
Country of birth
U.S. born 54,996
(42.36)
12,691
(74.19)
38,433
(39.58)
3,872
(24.76)
Foreign born 74,614
(57.47)
4,383
(25.62)
58,485
(60.24)
11,746
(75.12)
Missing 224
(0.17)
32
(0.19)
173
(0.18)
19
(0.12)
Insurance type
Emergency/Restricted
Medi-Cal
26,667
(20.54)
1,189
(6.95)
22,547
(23.22)
2,931
(18.74)
Medicare 9,726
(7.49)
48
(0.28)
2,722
(2.80)
6,956
(44.48)
Uninsured 11,191
(8.62)
1,557
(9.10)
8,752
(9.01)
882
(5.64)
Medicaid, incl. Medi-Cal 41,915
(32.28)
8,328
(48.68)
30,650
(31.57)
2,937
(18.78)
Other, incl. govt programs 12,340
(9.50)
2,017
(11.79)
9,632
(9.92)
691
(4.42)
Presumptive eligibility 19,520
(15.03)
2,535
(14.82)
16,418
(16.91)
567
(3.63)
Private 7,339 1,287 5,470 582

78
(5.65) (7.52) (5.63) (3.72)
Missing 1,136
(0.87)
145
(0.85)
900
(0.93)
91
(0.58)
Sex
Man 71,613
(55.16)
7,377
(43.13)
54,503
(56.14)
7,385
(47.23)
Woman 58,186
(44.82)
9,725
(56.85)
42,558
(43.83)
8,251
(52.77)
Missing 35
(0.03)
4
(0.02)
30
(0.03)
1
(0.01)
Race/ethnicity
Hispanic 89,022
(68.57)
12,604
(73.68)
66,598
(68.59)
9,820
(62.80)
Asian 6,067
(4.67)
469
(2.74)
3,932
(4.05)
1,666
(10.65)
Black 11,494
(8.85)
1,256
(7.34)
8,831
(9.10)
1,407
(9.00)
Other 9,057
(6.98)
921
(5.38)
7,016
(7.23)
1,120
(7.16)
White 5,928
(4.57)
547
(3.20)
4,486
(4.62)
895
(5.72)
Missing 8,266
(6.37)
1,309
(7.65)
6,228
(6.41)
729
(4.66)
CCI
None 116,196
(89.50)
16,710
(97.69)
87,601
(90.23)
11,885
(76.01)
Mild 9,107
(7.01)
305
(1.78)
6,115
(6.30)
2,687
(17.18)
Moderate 3,417
(2.63)
63
(0.37)
2,556
(2.63)
798
(5.10)
Severe 1,114
(0.86)
28
(0.16)
819
(0.84)
267
(1.71)
Data are reported as mean (SD) or n (%).
Abbreviations: ambulatory care sensitive condition (ACSC), confidence interval (CI),
emergency department (ED), odds ratio (OR).
*Percentage is out of 129,834 total individuals and 324,158 total ED visits.
Main Results
After adjusting for potential confounding factors, we found a statistically significant
association between documentation status and ED utilization for an ACSC in patients aged 26 to

79
64. We did not see a statistically significant association between documentation status and ED
utilization for an ACSC among patients in the 25 years or younger or 65 years or older age
groups. Among individuals aged 26 to 64, we found that undocumented patients had 1.3 higher
odds (95% CI = 1.23–1.38) of ED utilization for an ACSC compared to U.S.-born patients after
adjusting for covariates (p<0.001). We also found foreign-born documented patients had higher
odds of ED utilization for an ACSC compared to U.S.-born patients, and women had higher odds
of an ED visit for an ACSC compared to men (p<0.001). Furthermore, Hispanic and Black
patients, and patients who identified as Other race/ethnicity, had higher odds of an ED visit for
an ACSC compared to White patients (p<0.001). When compared to patients with private
insurance, patients with public insurance and those who were uninsured had higher odds of an
ED visit for an ACSC (p<0.001). Additionally, when compared to patients with no comorbid
conditions, patients with mild, moderate, or severe comorbidities had higher odds of an ED visit
for an ACSC (p<0.001). Our Hosmer-Lemeshow chi-square goodness of fit test statistic indicated
good model fit (p>0.05). Results for the multivariate logistic regression analysis of the
association between patients’ documentation status and ED visit for an ACSCs by age are
presented in Table 13.
Table 13. Multivariate Logistic Regression Results on the Association of Documentation Status
with ED Visit for ACSCs by Age
Age group
<25 years 26–64 years >65 years
Variable OR
(CI 95%) p-value
OR
(CI 95%) p-value
OR
(CI 95%) p-value
Documentation status
U.S. born (Ref) - - -
Foreign-born
documented
1.03
(0.81–1.29)
0.834 1.73
(1.65–1.81)
<0.001 1.03
(0.93–1.15)
0.540

80
Foreign-born
undocumented
0.99
(0.81–1.22)
0.952 1.30
(1.23–1.38)
<0.001 0.93
(0.81–1.07)
0.306
Sex
Man (Ref) - - -
Woman 2.34
(2.06–2.67)
<0.001 1.18
(1.14–1.22)
<0.001 1.22
(1.14–1.30)
<0.001
Race/ethnicity
White (Ref) - - -
Hispanic 1.34
(0.89–2.00)
0.159 1.38
(1.26–1.51)
<0.001 1.41
(1.21–1.65)
<0.001
Asian 1.15
(0.66–1.99)
0.622 1.13
(1.00–1.27)
0.05 1.15
(0.96–1.38)
0.140
Black 1.26
(0.79–2.01)
0.326 2.28
(2.07–2.51)
<0.001 1.68
(1.41–2.01)
<0.001
Other 1.44
(0.90–2.30)
0.131 1.34
(1.21–1.48)
<0.001 1.16
(0.96–1.39)
0.120
Insurance type
Private (Ref) - - -
Emergency/Restricted
Medi-Cal
1.79
(1.21–2.63)
0.003 2.08
(1.89–2.30)
<0.001 2.71
(2.18–3.37)
<0.001
Medicare 4.36
(1.85–10.26)
0.001 3.13
(2.78–3.53)
<0.001 1.83
(1.52–2.20)
<0.001
Uninsured 1.18
(0.81–1.72)
0.379 1.21
(1.09–1.34)
<0.001 1.28
(1.02–1.61)
0.037
Medicaid, incl.
Medi-Cal
1.79
(1.33–2.41)
<0.001 2.24
(2.05–2.44)
<0.001 1.83
(1.50–2.22)
<0.001
Other, incl. govt
programs
0.95
(0.65–1.40)
0.808 1.60
(1.45–1.77)
<0.001 1.52
(1.20–1.94)
0.001
Presumptive eligibility 1.54
(1.11–2.14)
0.011 1.56
(1.42–1.72)
<0.001 1.46
(1.13–1.87)
0.004
CCI
None (Ref) - - -
Mild 5.36
(4.10–7.02)
<0.001 4.46
(4.22–4.72)
<0.001 3.63
(3.28–4.02)
<0.001
Moderate 15.39
(8.97–26.41)
<0.001 5.48
(5.04–5.97)
<0.001 3.05
(2.57–3.61)
<0.001
Severe 20.36
(9.01–45.98)
<0.001 6.79
(5.83–7.90)
<0.001 3.08
(2.31–4.12)
<0.001
Notes: Findings were produced using county-wide aggregated data stratified by age (grouped into
<25, 26–64, and >65 years). Data sources: LADHS data (2016–2019). ED visit for ACSCs data were
obtained using discharge diagnosis codes.
Abbreviations: confidence interval (CI), odds ratio (OR), reference (Ref).

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Discussion
Our study of safety-net ED visit for an ACSC has significant clinical and financial
implications. According to the AHRQ, ED visits for an ACSC are considered potentially avoidable
with adequate access to quality ambulatory care. ACSC ED visits have been found to be more
costly than ACSC visits handled in an ambulatory, outpatient setting. In fact, studies have found
that costs for an ACSC ED visit can be twice as high, and payments nearly three times higher,
relative to an ACSC visit managed in an ambulatory, outpatient setting (e.g., hospital-based
clinic) (Galarraga et al., 2015). Furthermore, safety-net EDs are known for experiencing
overcrowding, which is an indicator of imbalance in the need for emergency care and the
hospital’s ability to provide the service or the number of patients exceeding the physical or
staffing capacity of the ED. Overcrowding has been shown to result in multiple consequences
for patients and providers. Among patients, ED overcrowding has been associated with an
increased risk and rate of adverse events, including morbidity and mortality, and increased
waiting time for care, which may delay diagnosis and treatment initiation. Among providers, ED
overcrowding has been associated with decreased welfare and work-related stressors (Savioli
et al., 2022). As a result, safety-net hospitals would benefit from reducing avoidable ED visits,
such as an ED visit for an ACSC, to reduce both overcrowding and health care expenditure.
In our sample of patients who received ED care at the largest Level I trauma center in
Los Angeles between 2016 and 2019, we found that 25% of patients had at least one ED visit for
an ACSC. The most common ACSCs among sample patients were hypertension and urinary tract
infections. Our study found that undocumented safety-net patients aged 26 to 64 had higher
odds of an ED visit for an ACSC compared to U.S.-born patients. Our study also found that

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women compared to men and uninsured or publicly insured versus privately insured patients
aged 26 to 64 had higher odds of ED visit for an ACSC. Furthermore, we found that racial ethnic
minorities versus White patients, and individuals with mild, moderate, or severe comorbid
conditions versus none had higher odds of an ED visit for an ACSC. Our results indicate that
more effort is needed to connect safety-net patients with higher odds of an ED visit for an ACSC
with quality ambulatory care to prevent avoidable safety-net ED visits for an ACSC.
Recent literature suggests undocumented immigrants experience unique barriers to
ambulatory care, specifically primary care. Studies have found that undocumented immigrants
struggle with securing timely appointments and managing high costs of care, and experience
fear of discovery and documentation status as well as misinformation regarding coverage and
immigration policies when seeking ambulatory care for their health needs (Saluja et al., 2019;
Yu et al., 2020). Sanctuary cities such as Los Angeles have developed programs to try to address
gaps in ambulatory care access experienced by uninsured, undocumented patients, but studies
have shown that these resources are underutilized (Yu et al., 2020). More research is needed to
understand barriers, improve quality, and increase utilization of ambulatory care services
among undocumented safety-net patients. Furthermore, by making greater effort to connect
undocumented patients to ambulatory care, safety-net hospitals may reduce overcrowding,
health care expenditure, and health disparities among undocumented safety-net patients.
Studies suggest that increased care coordination efforts in the safety-net setting may
successfully reduce ED utilization and hospitalizations for ACSCs. Promoting care coordination
and using patient navigators and integrated behavior health specialists (IBHS) offers a unique
opportunity to improve access to effective, efficient, and high-quality ambulatory care among

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safety-net patients. The use of patient navigators in the safety-net setting has been associated
with improved patient outcomes, including management of ACSCs, and improved clinical
engagement among patients with ACSCs. In a study that examined glycemic control among
patients with diabetes, patients who were matched with a patient navigator saw improved
glycemic control and clinic engagement (Horný et al., 2017). Additionally, a study that examined
IBHS in safety-net primary care clinics showed that rates of preventable inpatient utilization
significantly decreased among patients working with IBHS (Lanoye et al., 2017). Research on
care coordination efforts among undocumented immigrants in the safety-net setting is notably
missing. More research is needed to examine care coordination efforts among undocumented
safety-net patients. As mentioned previously, undocumented patients experience unique
barriers to ambulatory care and would likely benefit from increased care coordination efforts.
Future research is needed to both examine existing care coordination efforts at Los Angeles’s
largest safety-net hospitals and engage undocumented patients in identifying areas for
improvement.
Limitations
Our study investigated the association between documentation status and ED visit for
ACSCs in a sample of adult, Los Angeles County residents who visited the largest Level I trauma
center in Los Angeles. Our sample is subject to sampling bias and limits generalizability to U.S.-
born and foreign-born patients who seek care at other facilities. The literature indicates that
individuals who seek care at multiple ED sites have more chronic conditions and unmet health
needs. As a result, excluding these individuals from this analysis removes an important, distinct
group. Future studies should investigate the association between documentation status and ED

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visit for an ACSC among individuals who seek care at multiple ED facilities. Furthermore, though
studies that utilize EHRs for studying immigration status in health service research have had
favorable results related to accuracy, overestimation may be a problem (Heintzman et al., 2020;
Ross et al., 2017). Studies measuring documentation status in large datasets have used the
presence of Social Security number and insurance data and also reported overestimation (Ross
et al., 2017). Thus, this study faces the traditional limitations of using medical record and claims
data, including but not limited to incomplete or missing data, difficulty with variable
interpretability, and documentation and reporting variability (Senathirajah et al., n.d.).
Despite these limitations, results represent a large population of urban safety-net
patients who sought emergency care for an ACSC in Los Angeles. Results inform future research
aimed at reducing avoidable ED visits and promoting access to ambulatory care access among
safety-net patients. This study provides improvements to the existing literature through the
employment of novel categorizations and taxonomies, including the use of unique patient
identifiers for the classification of documentation status, and applies the AHRQ PQI criteria to
identify high-risk populations for ACSC-related ED visits. Results are clinically relevant for policy
and health equity efforts designed to reduce disparities in health and health access among
vulnerable populations, specifically undocumented safety-net patient populations. Our study
suggests that improving ambulatory care access and access to comprehensive insurance, such
as private insurance, for undocumented patients aged 26 to 64 may reduce avoidable ED visits
for ACSCs, which may thereby reduce ED overcrowding and expenditure and improve health
outcomes in undocumented patient populations.

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Summary
After our quantitative analysis (detailed above), the question arose of how, if at all, the
emergency-care seeking processes and behaviors of undocumented patients outlined in the
original theoretical framework would differ if they were to be examined through the lens of
patients’ ACSC status. We wondered if applying this lens would provide new perspective and
inform our growing understanding of the unique barriers to ambulatory care experienced by
undocumented safety-net ED patients with an ACSC and those seen for other conditions. In the
next study, we will explore this question through the implementation of a qualitative secondary
analysis.
Conflicts of Interest
None to report.
Funding
Agency for Healthcare Research and Quality Dissertation Award Recipient (R36).
Acknowledgments
Southern California Clinical and Translational Science Institute and Leonard D. Schaeffer
Center for Health Policy and Economics.

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Chapter 4: Contextualizing Undocumented Safety-Net Patients’ Emergency Department Visit
for an Ambulatory Care Sensitive Condition (ACSC): A Qualitative Secondary Analysis
Study Objective
The goal of this investigation was to extend and contextualize our understanding of the
unique emergency care-seeking processes described by undocumented immigrants with an
ACSC by conducting a qualitative secondary analysis (QSA).
Background
Previous studies have found that undocumented immigrants may be at greater risk of
ED utilization for ACSCs compared to U.S.-born patients. However, the extent to which reduced
access to ambulatory care and health insurance influences safety-net ED care-seeking among
undocumented immigrants is not fully understood.
Methods
We conducted a QSA of interviews collected between February 2019 and August 2022
at Los Angeles’s largest safety-net hospital. Interviews analyzed were conducted among
undocumented participants (n=10) who reflected on their ED care-seeking processes and
perceptions of ambulatory care. We identified patients whose ED visit involved an ACSC using
medical record abstraction and according to AHRQ criteria. Interviews conducted among
patients with an ACSC were analyzed separately from those seen for other conditions. Analytic
memos were used to provide detailed record of researchers’ thought processes and reflections
throughout the iterative process. Constant comparison was used to develop themes related to
participants’ ED care-seeking processes and ambulatory care access.

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Results
A total of 10 undocumented ED patient interviews were analyzed, including five with an
ACSC (n=5) and five seen for other conditions (n=5). Both undocumented participants with an
ACSC and those seen for other conditions described concurrent and divergent ED care-seeking
processes. All participants described seeking ambulatory care to cope with their symptoms yet
without resolution. Undocumented participants seen for other conditions described receiving
provider referrals for ED care-seeking and described uncomfortable experiences of bias when
interacting with providers, which they perceived to be associated with their documentation
status and lack of insurance. Undocumented participants with an ACSC described having little to
no choice but to seek ED care and preferred to seek ED care over ambulatory care because they
perceived ED care to offer higher quality care and greater affordability.
Conclusions
Our study findings suggest that the experiences of undocumented participants seen for
other conditions were distinct from those of participants with an ACSC. Undocumented
participants seen for other conditions described ED care-seeking pathways that were consistent
with having ambulatory care. To reduce avoidable ED visits in the safety-net setting, hospitals
should prioritize reducing barriers to ambulatory care access described by undocumented
patients, including scheduling difficulties and high costs of care.

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Introduction
Undocumented immigrants were excluded from the ACA, a decision that upheld
established inequities in public benefits, particularly health care access, among this population.
Due in large part to exclusion from the ACA, undocumented immigrants’ ability to obtain
comprehensive health insurance remains extremely limited. Generally, undocumented
immigrants can obtain health insurance coverage by purchasing private insurance from
brokerages and agencies, accessing employer-sponsored programs, and accessing emergency
Medicaid. Unfortunately, these options come with several barriers and limitations. Excluding
undocumented immigrants from the ACA also excludes the population from receiving the
government subsidies and tax credits introduced in the policy, leaving undocumented
immigrants able to only purchase coverage directly from private insurance providers without
government financial assistance, which can be incredibly costly. Moreover, obtaining insurance
coverage through employer-sponsored programs is limited because participation is only
required for employers with 50 or more full-time employees, and legal employment requires
proof of citizenship, which most undocumented immigrants do not have. Though
undocumented immigrants remain eligible for emergency Medicaid and other such services,
coverage is limited to emergency situations only with coverage for follow-up care (Keck School
of Medicine, USC, 2023).
In addition to experiencing federal policy-related barriers to health care access,
undocumented immigrants also experience barriers at state and local levels. Despite California
being home to over 2.7 million undocumented immigrants, resident undocumented immigrants
are not eligible to purchase comprehensive health insurance through the marketplace.

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Furthermore, few jobs offer undocumented immigrants insurance coverage. This is particularly
relevant in Los Angeles, where, according to the Pew Research Center, more than 951,000
undocumented immigrants were residing in Los Angeles County in 2019, making it the city with
the second-largest undocumented population in the country (Passel, 2019). Locally funded
programs such as Los Angeles’s My Health LA have been created in an attempt to reduce
inequities in health access among ACA-ineligible populations (McConville et al., 2015).
However, studies have found that such services remain underutilized and are limited in their
ability to provide undocumented immigrants with comprehensive care, particularly due to lack
of health insurance (Yu et al., 2020). Lack of insurance increases undocumented immigrants’
risk for experiencing gaps and barriers to ambulatory care, which has been found to reduce
primary care utilization and increase hospitalizations (Nwadiuko et al., 2021). Undocumented
immigrants have been found to have greater risk for poor maternal health outcomes and
limited access to health insurance coverage as compared to documented immigrants or U.S.-
born individuals (Alberto et al., 2020; Atkins et al., 2017; Balakrishnan & Jordan, 2019; AmuedoDorantes & Lopez, 2017; Atkins et al., 2018; Cervantes et al., 2021; Cha et al., 2019).
Additionally, documentation status has been associated with lower use of preventive health
services in a timely manner, including preventive health screenings (Guerrero et al., 2016;
Torres & Waldinger, 2015).
ACSCs are “conditions for which good outpatient care can potentially prevent the need
for hospitalization, or for which early intervention can prevent complications or more severe
disease” (Agency for Healthcare Research and Quality, 2021). ACSCs are “intended to reflect
issues of access to, and quality of, ambulatory care in a given geographic area” (Agency for

90
Healthcare Research and Quality, 2021). Hospitalizations for conditions such as uncontrolled
diabetes, COPD, asthma, heart failure, urinary tract infections, community-acquired
pneumonia, and hypertension are all considered potentially preventable with adequate access
to outpatient care. Studies have found that ED visits for ACSCs are costly and may have negative
consequences on safety-net patients, caregivers, and care providers, which can affect patient
outcomes (Cervantes et al., 2020; Donoho et al., 2018; Erickson et al., 2020). As indicated in
study 2, undocumented immigrants have higher odds of ED utilization for an ACSC compared to
U.S.-born patients after adjusting for covariates, including insurance. More research is needed
to further our understanding of the unique barriers to ambulatory care experienced by
undocumented patients seeking ED care for an ACSC as compared to those seeking ED care for
other conditions.
QSA involves performing additional analyses on the principal qualitative dataset, which
may include analyzing a subset of the original data, applying new perspectives or focus to the
original data, or validating or expanding findings from the original data (Goodwin, 1997; Tate &
Happ, 2018). Types of QSA are classified by the relationship between the primary and
secondary research questions, which generally includes investigating questions different from
the primary study, applying a unique theoretical perspective, or extending the primary work
(Heaton, 2008). QSA offers unique benefits when examining research questions among
vulnerable populations or investigating sensitive topics. By maximizing the use of existing data,
QSA permits new questions to be asked of data collected previously from an assembled cohort,
maximizing participants’ time and effort in the primary study. This is particularly important
when conducting research among vulnerable populations or on sensitive topics because it

91
reduces the unnecessary burden of asking participants to divulge additional sensitive details to
researchers when answers to those questions may already exist in the primary dataset
(Fielding, 2004). By reexamining a subset of interviews from a principal dataset on emergency
care-seeking processes described by undocumented patients, we aimed to synthesize and
contextualize our growing understanding of the relationship between documentation status,
ambulatory care access, and safety-net ED utilization through the lens of patients’ ACSC status.
Goal of This Investigation
The goal of this investigation was to extend and contextualize our understanding of the
unique emergency care-seeking processes described by undocumented immigrants by
conducting a QSA and reexamining patients’ emergency care-seeking processes according to
their ACSC status.
Methods
Overview of the Principal Data
The principal data were collected using a grounded theory approach for the purposes of
developing a theoretical framework of safety-net patients’ emergency care-seeking processes.
Interview questions gathered information about participants’ decision-making processes and
perceptions of ED care-seeking. Participants were asked about potential influences of ED careseeking such as documentation status and perceptions of ambulatory care. Medical record
abstraction was used to gather additional participant data for future analyses, including
discharge diagnosis code(s) and insurance type. All demographic and clinic information was
uploaded to a secure, HIPPA-compliant server provided by the participating institution. The
principal research team was composed of a PhD student (C.N.R.), emergency medicine

92
physician (E.B.), two medical students, and three undergraduate students. All study procedures
were conducted at the largest public hospital and Level I trauma center ED in Los Angeles.
Ethical standards were upheld using informed consent and confidentiality, and participants
were able to withdraw from study activities at any time.
Participant recruitment and data analysis began in February 2019, was interrupted by
the COVID-19 pandemic in March 2020, and restarted in March 2022. Study recruitment
concluded in August 2022 at the point of theoretical saturation. Recruitment took place among
patients who were 18 years or older, were pending admission to the inpatient hospital, and had
an ESI score of 3 or greater. Their reason for admission included abdominal pain or
nausea/vomiting. Patients who spoke English or Spanish, and whose provider signed off on
their mental and physical ability to partake were invited to participate in a 30-minute, face-toface, audio-recorded interview. At the conclusion of the interview, patients received a $10 gift
card for their participation.
The principal study codebook was derived from the data and based on analysis of
semistructured interviews. Emerging themes were related to participants’ ED care-seeking
processes and influences of ED care-seeking. The research team conducted four rounds of
independent coding with comparison for the development of the codebook, which indicated
excellent agreement (pooled K=0.94) and contained seven axial themes and 17 subthemes
describing patients’ ED care-seeking processes and influences of ED care-seeking.
The principal analytic dataset was composed of 25 safety-net ED patients, 10 of whom
identified as undocumented, and 15 as documented (n=7 foreign-born documented and n=8
U.S. born). All participants who were interviewed disclosed their documentation status.

93
Participants were predominantly Hispanic/Latinx and insured through Medi-Cal. Thirteen
participants identified as men, and 12 identified as women. Participant ages ranged from 27 to
78 years with a mean age of 49 years (SD 13.08). Mean ESI among study participants was 2.8,
indicating that patients were being seen for medium-risk situations with moderate levels of
pain or distress. Participants’ self-reported country of birth included Mexico (56%), U.S. (32%),
El Salvador (1%), Honduras (1%), and Colombia (1%).
Study Design
Expanding the Principal Study. As mentioned previously, data collection for the
principal study was interrupted by the COVID-19 pandemic from March 2020 to March 2022. At
the time of study interruption, a total of 14 interviews had been collected and analyzed. The
research team used this time to explore emerging themes for future analysis, including ED visits
for ACSCs. To continue exploring this emerging theme, open-ended questions and probes were
added to the Spanish- and English-language interview guides to explore patient perceptions of
ambulatory care access, particularly primary care. Interview guides underwent multiple rounds
of revision and piloting throughout the data collection and analysis process, as is custom in
qualitative research. Revisions identified and resolved issues of organization and language,
addressed gaps in the emerging data, and explored new and emerging themes. All revisions
were resolved via consensus among members of the research team. Additional piloting was
conducted for the Spanish-language interview guide to ensure translations were appropriate
and culturally competent. Study personnel piloted the Spanish-language interview guide with
native Spanish-speaking ED research staff who had not read the initial English version of the
documents. Piloting identified and resolved any issues related to translation and cultural

94
competence. The expanded English- and Spanish-language interview guides were approved
prior to the data collection that restarted in March 2022. Table 14 provides a sample of
interview questions related to patient perceptions of ambulatory care access that were added
to the interview guides for additional analysis.
Table 14. Sample Interview Questions and Probes
When was the last time, if ever, that you tried to access preventive or primary health
services? How was that experience?
What helps you access preventive or primary health services? What problems might you
encounter trying to access preventive or primary health services? Could you tell me the
sources of these problems?
How, if at all, has your experience using primary or preventive care services influenced your
decision to come to the emergency department for care?
Creating the Secondary Dataset. We created a subdataset composed of all
undocumented patients who were interviewed in the principal dataset (n=10). To classify
documentation status, we reviewed participants’ self-reported documentation status, which
was collected during the interview using a brief, six-item questionnaire adapted from RAND’s
LA Family and Neighborhood Survey (RAND Corporation, 2018). Participants who reported
being born outside the U.S., lacked permanent residence, and did not have a visa or other
temporary permission to live or work in the U.S. were classified as undocumented. Participants
who reported being born either in the U.S., or outside the U.S. but with legal documentation to
work or live in the U.S., were classified as documented. Documentation status classifications
were added to participants’ descriptive data in Dedoose analytic software (Dedoose Support,
n.d.). Using Dedoose’s dataset workspace filtering function, we created our final analytic
dataset, which comprised all transcripts, memos, and codes pertaining to undocumented
participants.

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Data Collection
Identifying ACSC Status
We used medical record abstraction to identify undocumented participants’ ACSC
status. Undocumented participants’ medical record numbers and interview dates were used to
identify discharge diagnosis codes in their medical records associated with their interview visit.
All discharge diagnosis codes and descriptions pertaining to the participants’ interview visit
were uploaded to a HIPAA-compliant server for analysis. Data in the server was deidentified,
downloaded to STATA analytic software, and reviewed for the presence of ICD-10-CM codes
pertaining to any one of the following nine ACSCs: diabetes, short-term complications;
diabetes, long-term complications; COPD or asthma in older adults; hypertension; communityacquired pneumonia; urinary tract infection; uncontrolled diabetes; and asthma in younger
adults, as indicated by the AHRQ. We created a binary outcome variable to reflect participants’
ACSC status. If participants had any discharge diagnosis code(s) pertaining to an ACSC during
their visit, they were classified as having an ED visit for an ACSC. Participants with no discharge
diagnosis codes pertaining to an ACSC during their visit were classified as having no ED visit for
an ACSC. Participants’ ACSC status was added to their descriptive data in Dedoose analytic
software (Dedoose Support, n.d.).
Data Analysis
Interviews among participants with an ACSC were analyzed separately from those of
participants seen for other conditions. We compared codes related to ambulatory care access
and ED care-seeking by participants’ ACSC status. We used constant comparison to develop
new themes related to participants’ ED care-seeking processes and ambulatory care access that

96
emerged from the data. Analytic memos were used to provide detailed record of researchers’
thought processes and reflections throughout the iterative process. Coding and analysis were
conducted using Dedoose analytic software (Dedoose Support, n.d.). Special attention was
given to codes related to participants’ experiences with and perceptions of ambulatory care
access. Analyses were conducted by members of the research team that were involved in the
parent study and familiar with study documents and participants. Once specific themes related
to ACSC status were identified, themes were compared for convergence and divergence across
participants’ ACSC classifications.
Results
Participant Characteristics
A total of 10 undocumented participant interviews were analyzed, including five among
participants with an ACSC (n=5) and five among those seen for other conditions (n=5).
Participants were mostly men (60%) and had a mean age of 50.5 years. Participants all
identified as Hispanic/Latinx and were predominantly Spanish speaking. Furthermore, nine
participants were born in Mexico (90%), and five were insured through Emergency/Restricted
Medi-Cal (50%). Participants’ mean ESI score was 2.8, indicating that participants were seen for
medium-risk situations with moderate levels of pain or distress. Participants with an ACSC had a
mean age of 51 years and were all born in Mexico. Participants seen for other conditions had a
mean age of 50 years and were born in Mexico (n=4) and Honduras (n=1). Table 15 presents
participant characteristics by ACSC status.

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Table 15. Participant Characteristics by ACSC Status
Characteristic
All foreign-born
undocumented
participants
n=10 (%)
Foreign-born
undocumented
participants with ED
visit for an ACSC
n=5 (%)
Foreign-born
undocumented
participants with an
ED visit for other
condition(s)
n=5 (%)
Sex
Woman 4 (40.00) 2 (40.00) 2 (40.00)
Man 6 (60.00) 3 (60.00) 3 (60.00)
Age
Range 39–72 43–60 39–72
Mean (SD) 50.5 (9.94) 50.6 (6.54) 50.4 (13.39)
ESI score
Range 2–3 2–3 2–3
Mean (SD) 2.8 (0.42) 2.8 (0.45) 2.8 (0.45)
Race/ethnicity
Hispanic/Latinx
10 (100.00) 5 (100.00) 5 (100.00)
Insurance type
Presumptively eligible
for Medi-Cal 2 (20.00) 1 (20.00) 1 (20.00)
Emergency/Restricted
Medi-Cal 5 (50.00) 2 (40.00) 3 (60.00)
Medicaid, including
Medi-Cal 3 (30.00) 2 (40.00) 1 (20.00)
Language of interview
Spanish 10 (100.00) 5 (100.00) 5 (100.00)
Country of birth
Mexico 9 (90.00) 5 (100.00) 4 (80.00)
Honduras 1 (10.00) 0 (0.00) 1 (20.00)
Undocumented Participants with an ED Visit for an ACSC. Participants with an ACSC
described seeking other forms of care, particularly ambulatory care, prior to seeking ED care.
Unsuccessful care-seeking attempts were characterized by long appointment wait times and

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receipt of treatment without symptom resolution. Participants who did not attempt to seek
ambulatory care prior to seeking ED care perceived both that ambulatory care services lacked
the necessary equipment to adequately treat their symptoms and that patients would
experience financial barriers to care-seeking (e.g., high cost of care), inconsistent medical
record keeping systems, and scheduling difficulties. Participant perceptions of ambulatory care
were informed by their previous care-seeking experiences. Participants with an ACSC perceived
safety-net EDs to be a more effective and efficient care-seeking option than available
ambulatory care options for resolving their care needs. Table 16 provides supportive quotes of
participant perceptions that EDs offer better care and equipment than ambulatory care, as
described by undocumented safety-net patients with an ACSC.
Table 16. Themes and Supportive Quotes among Undocumented Safety-Net Patients with an
ACSC
Theme Supportive quotes
Perceiving ED to
offer better care
and more
equipment
“I don’t have a primary care doctor right now, but let me tell you, I have
liked how they’ve treated me here. [I] always keep that in mind when
deciding where to go [get health care]. There are other hospitals that
don’t even want to receive you [patients] now that there’s a pandemic.
They just check you and give you medicine. That happened to my
boyfriend. They checked him, they gave him antibiotics, and they gave
him pills. No, it [the treatment] didn’t work; he was getting worse.
That’s when I told him, ‘Come to this hospital [general hospital],’ and
this is where they helped him. I have been here before and, well, I know
that it’s one of the hospitals that has the machines [equipment] and
more . . .”
—Hispanic woman, 48, undocumented, ED visit for an ACSC
“I have already been to this hospital on other occasions. I think that in
this hospital is where I’ve received the best attention in respect to the
condition that I have, diabetes. I have come in for other circumstances
and have been very well attended. I’ve left feeling really good. You keep
that in mind. Apart from that, this is the place where they were going to
serve me better than some clinic. If I were to go to the clinic that I
normally go to, they don’t have neither the specialties that they have

99
here nor the gadgets they have here. That’s why I chose to come here. I
knew I was very sick, and where better than here, where I could be
served better than in another part?”
—Hispanic man, 60, undocumented, ED visit for an ACSC
“Over there, in other hospitals, they told me, ‘Go instead to the general
hospital, because your bones are already too worn out,’ or who knows
what they told me. They said, ‘They’ll likely cut off your foot.’ I said, ah,
how great [snorts laughing], but well, here we are, everything is bigger
here. I think the name says it all, right?”
—Hispanic man, 48, undocumented, ED visit for an ACSC
Undocumented Participants with an ED Visit for Other Conditions. Participants seen
for other conditions also described seeking ambulatory care prior to ED care. Unlike
participants with an ACSC, however, those seen for other conditions described successful
ambulatory care-seeking attempts, which were characterized by connecting with a provider and
securing an appointment. Though participants seen for other conditions were able to
successfully seek ambulatory care, their care-seeking attempts did not lead to symptom
resolution. Participants with an ACSC described securing ambulatory care only to be referred to
ED care by an ambulatory care provider, including CHC, urgent care, and specialty care
providers. Participants described being seen by ambulatory care providers and being given
“emergency papers,” which they perceived to be ED referrals that offered them faster care
access (e.g., “ED appointments”) and reduced or no-cost care. Table 17 provides supportive
quotes from participants who were seen for other conditions and described receiving referrals
from other providers.

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Table 17. Themes and Supportive Quotes Pertaining to Referrals Theme among
Undocumented Safety-Net Participants Seen for Other Conditions
Theme Supportive quotes
Receiving
referral from
another
provider
“This problem [symptoms] started two weeks ago. [Takes a deep breath.] I
started feeling a medium level of pain the first week, and I made an
appointment where I go to the doctor [CHC]. They gave me an appointment
for the following week, and I went, and they gave me laboratory exams and
all that. When the specialist saw me, she was the one who referred me
over here to the hospital. She immediately gave me the paper so that I
could come here.”
—Hispanic woman, 41, undocumented
“The doctor [oncologist] told me to come to [the] emergency department
because I told her that I had fallen recently, and it’s not recommended to
fall. I did have a bruise on my toe, and the sole of my foot was really
swollen. She told me go to the emergency department.”
—Hispanic woman, 72, undocumented
“Well, look; it is just that, honestly, you know that it is the emergency
department, and we [undocumented patients] do not have to pay for
anything. The emergency paper that they [doctors] give us helps us not get
charged. We don’t have enough money to pay a private clinic that is super
expensive. Therefore, this is what benefits us.”
—Hispanic man, 39, undocumented
“In the red folder I brought with me, I have the paper that they [urgent care
doctors] gave me. I brought it with me to the appointment [at the
emergency department]. It was the people from urgent care that gave it to
me.”
—Hispanic man, 46, undocumented
Additionally, participants seen for other conditions described being made to feel like
second-class citizens due to their documentation status. Participants perceived that their
documentation status decreased their access to quality and comprehensive care, particularly
due their lack of health insurance options. Furthermore, participants perceived that their
documentation status made them less of a priority to providers because they were not insured
and might not be able to pay for health care needs to the same extent as insured or

101
documented patients. Additionally, participants described uncomfortable experiences with
providers, which they perceived to have occurred a result of provider judgment of their
documentation status and financial limitations. Despite experiencing discrimination and stigma,
participants also expressed gratitude for emergency services, which they knew were
guaranteed regardless of their documentation status. Table 18 provides supportive quotes from
participants who described being made to feel like second-class citizens due to their
documentation status, as described by undocumented participants seen for other conditions.
Table 18. Supportive Quotes Pertaining to Secondary Citizens Theme among Undocumented
Participants Seen for Other Conditions
Secondclass
citizens
“I pay taxes, and in one way or another I think I am contributing [to the U.S.
economy]. And that is not to say that I am charging or demanding anything, no.
It’s simply that, well, I think that I am also competing with mine. I have always
said, there are many people [undocumented individuals] that are here, and
sometimes we [undocumented individuals] do not know how to give thanks to a
country that receives us, to a country that gives services and that, sometimes,
yeah, sometimes treats us a little, not bad, but with a hard hand. It is more
difficult for us [undocumented individuals] to be among the benefitted people. I
got COVID two times, and it hit me really bad; it hit me hard. I didn’t work for a
little over a month the first time I had it, right when the pandemic started. I
wanted to apply for food help and all that, but since I was not a resident, I didn’t
qualify or obtain it. So, sometimes, it’s like I told you, a little too hard handed.
For someone that doesn’t have medical insurance, it is complicated [residing in
the U.S.].”
—Hispanic man, 54, undocumented, ED visit for an ACSC
“My point of view is that they [U.S.-born and documented persons] are always
before [undocumented persons], right? It’s not the same. The paper—
citizenship—has a lot to do with everything. [An undocumented person] doesn’t
compare to them [U.S.-born or documented persons]. [An undocumented
person] won’t come before them [U.S.-born or documented persons].”
—Hispanic man, 48, undocumented, ED visit for an ACSC
“I know that they [providers] give preference to the people who have papers
[U.S.-born or documented persons] since they can get more [money] than they
can get from us [undocumented persons]. They [providers] give them [U.S.-born
or documented persons] better medicine. Why? Because the government can

102
pay. On the other hand, they give us [undocumented persons] attention, but I
think they give them [U.S.-born and documented persons] better attention.
They [U.S.-born and documented persons] have more privilege than
[undocumented persons]. But we [undocumented persons] have the joy of
knowing that even though we don’t have papers, well, they [providers] can’t
deny us those services. But I know that the people who do have papers have
more privileges. [Undocumented persons] would like to have papers and to be
treated the same [as U.S. citizens or documented persons]. But, like I said, well,
they [providers] don’t stop assisting us [undocumented persons]. That’s grand.
We [undocumented persons] should be grateful because even though we don’t
have papers, they [providers] won’t stop attending us.”
—Hispanic woman, 48, undocumented, ED visit for an ACSC
“There are doctors that you notice are not interested in whether you do or don’t
have papers or that your status is legal or illegal. And it shows in others—I am
not talking about this hospital, but elsewhere—where you can feel the
harshness of when you are not fully taken into consideration. I’ve suffered this
before. I will never forget that feeling of rejection from that past doctor . . . It
makes [me] feel uncomfortable . . . I haven’t seen them [the doctors] put care
about the status of patients here, but in other places [hospitals and clinics] I
have. It’s like they are afraid; it’s like they’d say, ‘This man has no papers. Let’s
invest all this stuff [resources] in him, and what if there is no one who takes
responsibility? Or what if he leaves, or they throw him out [deport him]; who
will pay [for the services]?’ You always feel that rejection when [a provider] is a
little cold with you. When someone is treating you differently, you can feel it.
You realize it.”
—Hispanic man, 60, undocumented, ED visit for an ACSC
Summary of Updated Theory. Our analyses found that undocumented patients who
came to the ED with an ACSC had ED care-seeking processes distinct from those who came to
the ED to be seen for other conditions. Participants with an ACSC described being prompted to
seek ED care following a failed attempt to seek ambulatory care. Furthermore, participants with
an ACSC described preferring to seek ED care over ambulatory care based on their perception
that ambulatory care facilities both lack the necessary equipment to adequately treat their
symptoms and that patients will encounter high-cost health care, inconsistent medical record
systems, and scheduling difficulties. Participants seen for other conditions described being

103
referred to ED care by ambulatory care providers and receiving “emergency papers,” which
they perceived to be referrals that led to shorter ED wait times and low-to-no-cost care.
Furthermore, participants seen for other conditions perceived their documentation status as a
barrier to health care access and reflected on experiences of discrimination and stigma when
seeking care. Figure 8 presents our updated theory of emergency care-seeking, which was
originally presented in study 1, among undocumented patients with an ACSC and those seen for
other conditions.
Figure 8. Revised Theoretical Framework of Emergency Care-Seeking among Undocumented
Safety-Net Patients with an ACSC and Those Seen for Other Conditions
Discussion
Undocumented patients with an ACSC preferred to seek ED care over ambulatory care,
largely based on their perception that EDs offer higher-quality and lower-cost care. The
experiences of patients with an ACSC were similar to those of patients in other studies that
have investigated the relationship between ambulatory care and ED utilization. Previous studies
have found that patients with low socioeconomic status, such as patients in the safety-net
setting, prefer acute care over ambulatory care because they perceive it to be more accessible
and of higher quality (Kangovi et al., 2013). Furthermore, our study found that long

104
appointment wait times and high cost of care limited patients’ ambulatory care utilization,
which is consistent with the literature (Rojas, 2016).
Our findings have significant implications for health care expenditure. According to the
AHRQ, ED visits for an ACSC are considered potentially avoidable with adequate access to
quality ambulatory care. ACSC ED visits have been found to be more costly than ACSC visits
handled in an ambulatory, outpatient setting. In fact, studies have found that costs for an ACSC
ED visit can be twice as high, and payments nearly three times higher, relative to an ACSC visit
managed in an ambulatory, outpatient setting (e.g., hospital-based clinic) (Galarraga et al.,
2015). Our findings suggest that avoidable ED visits may be reduced by prioritizing connecting
undocumented patients with an ACSC to quality ambulatory care.
Undocumented patients seen for other conditions described care-seeking pathways that
were consistent with adequate access to ambulatory care. Participants described seeking
ambulatory care and being referred to ED care by other providers, including CHC, urgent care,
and specialty care providers. Participants were given “emergency papers” by ambulatory care
providers, which they perceived to be ED referrals that offered them faster and lower-cost ED
care. Few studies have investigated the relationship between primary care referral and ED
utilization (Hill et al., 2016). To date, no studies have been published identifying ED referrals
among undocumented safety-net patients. Participants seen for other conditions described
instances of uncomfortable interactions with providers, which they perceived to be associated
with stigma related to their documentation status and lack of insurance. Participants seen for
other conditions inferred that providers hesitated to provide them with comprehensive
treatment and treated them as inferior to documented patients who had access to insurance

105
due to concerns of payment. Previous studies have found that undocumented patients
experience fear and stigma, which act as barriers to health care (Hacker et al., 2015; Yu et al.,
2020). Given exclusionary policies that limit undocumented individuals’ ability to obtain
comprehensive health insurance, patients have little to no ability to change the circumstances
of their care coverage.
Our study suggests more efforts are needed to improve accessibility and quality of
existing safety-net ambulatory care resources available to undocumented immigrants. Patients
we interviewed specifically discussed struggling to access ambulatory care due to high costs of
care, long appointment wait times, and facilities that lacked necessary equipment to
adequately treat their symptoms. Future research should consider collaborating with patients
and safety-net ambulatory care services to conduct resource evaluations. These evaluations
should prioritize identifying and addressing barriers to safety-net ambulatory care as described
by undocumented patients with previous negative or unsuccessful care-seeking attempts. By
doing so, ambulatory care services may be able to increase utilization of existing services by
undocumented patients and reduce potentially avoidable ED visits for ACSCs among the
population. Additionally, promoting care coordination, such as using patient navigators and
IBHS, offers a unique opportunity to improve access to effective, efficient, and high-quality
ambulatory care among safety-net patients. The use of patient navigators in the safety-net
setting has been associated with improved patient outcomes, including management of ACSCs
and clinical engagement among patients with ACSCs. However, research on care coordination
efforts among undocumented immigrants in the safety-net setting is notably missing. More
research is needed to examine care coordination efforts among undocumented safety-net

106
patients. As mentioned previously, undocumented patients experience unique barriers to
ambulatory care and would likely benefit from increased care coordination efforts. Future
research is needed to both examine existing care coordination efforts at Los Angeles’s largest
safety-net hospitals and engage undocumented patients in identifying areas for improvement.
The frequency and process of ambulatory care referrals to the ED among
undocumented patients seen for other conditions must be further investigated. More research
is also needed to examine risk factors for ambulatory care referrals to the ED, including
characteristics of ambulatory care providers who refer patients to the ED and clinical and
demographic characteristics of patients who are referred to the ED by ambulatory care
providers. Furthermore, research should conduct key informant interviews among ED providers
to gain perspective on the context and effect, if any, of ambulatory care referrals on ED care.
More research is also needed to understand and contextualize the “emergency papers”
described by undocumented patients. Research should investigate what these “emergency
papers” contain and their role in receipt and quality of care once patients arrive at the ED. Key
informant interviews among ED providers, ambulatory care providers—particularly in the CHC
setting—and ED triage nurses who primarily receive patients in the ED could extend these
findings and contextualize the role of referrals in ED utilization. More efforts are also needed to
reduce documentation status-based discrimination and stigma in the health care setting.
Previous studies that have investigated experiences of stigma in the health care setting among
undocumented patients suggest that modifying current policies to allow undocumented
immigrants increased options to access care could help reduce suffering and stigma and

107
encourage clinicians to both recognize patients’ humanity and validate their medical needs
(Chandler et al., 2012).
Limitations
Our study has several limitations. In conducting theoretical sampling of patients, we
may have biased our sample to include participants with more facilitators or more barriers to
seeking health care. However, given that this is a qualitative study, quantifying the significance
of patients’ health care barriers was outside the scope of this study. Further work is needed to
inform transferability of findings in other populations. Additionally, previous studies have
indicated that the timing of QSA is important, relative to the original study, because findings
from the original study may influence the secondary study. More specifically, concerns around
introducing bias and outdating have been discussed when implementing QSA. Given that data
collection for the original study and the subsequent study were performed concurrently, we are
not concerned that data was outdated or that historical bias was introduced. Furthermore, we
do not anticipate characteristics of the phenomena to have changed between analyses.
Despite limitations, this study also holds several strengths. We implemented the AHRQ’s
criteria for identifying ACSCs in our sample. We also prioritized the experiences of
undocumented patients who sought safety-net ED care, a population historically
underrepresented in the literature. In addition, our findings established that ED care-seeking
processes among undocumented immigrants differ by patients’ care needs and conditions.
Undocumented patients with an ACSC described preferring ED care to ambulatory care due to
perceptions of higher quality, lower cost, and easier access. Undocumented patients seen for
other conditions, however, described being referred to the ED by ambulatory care providers.

108
Study findings contribute to the literature by providing a more comprehensive understanding of
ED care-seeking processes among both undocumented safety-net patients with an ACSC and
those seen for other conditions.
Conflicts of Interest
None to report.
Funding
Agency for Healthcare Research and Quality Dissertation Award Recipient (R36).

109
Chapter 5: Conclusions
Summary of Findings
This dissertation used a sequential mixed-methods approach to examine the association
between documentation status and safety-net emergency care-seeking at the largest safety-net
hospital in Los Angeles. We developed a theoretical framework for the emergency care-seeking
processes described by a sample of safety-net patients who also highlighted the distinct
processes described by undocumented patients (study 1). Using a grounded theory approach,
we outlined undocumented patients’ unique barriers to ambulatory care-seeking such as long
wait times for appointments, high costs of care, and underresourced facilities, which influenced
their decisions to seek safety-net ED care. These unique barriers were not described among
U.S.-born or foreign-born documented patients. Throughout the iterative process, we
determined that documentation status influences ambulatory care access and safety-net ED
utilization. However, the extent to which documentation status influences ED utilization for
ACSCs remained unclear.
To investigate the association between documentation status and ED visit for an ACSC,
we conducted an age-stratified multivariate logistic regression in a sample of n=129,834 safetynet patients (study 2). Informed by our theoretical framework, we hypothesized that
undocumented safety-net patients would have higher odds of ED utilization for an ACSC
compared to U.S.-born patients. We found that undocumented patients between the ages of 26
and 64 have 1.3 higher odds of ED use for an ACSC compared to U.S.-born patients after
adjusting for sex, race, ethnicity, insurance type, and comorbidities. The literature suggests that
potential reasons for higher odds of ED utilization for an ACSC among undocumented patients

110
may include barriers to primary care such as timely appointments, cost of care, fear,
misinformation, and misperceptions of coverage and immigration policies. Sanctuary cities such
Los Angeles have developed programs to try to address the gaps in ambulatory care access
experienced by undocumented patients who do not have access to comprehensive insurance
coverage, though studies have shown that these resources are underutilized. Our study 1
findings indicate that these resources are underutilized due to patients’ previous negative
experiences with seeking ambulatory care services. More funding and greater efforts are
needed to address barriers, improve quality, and ultimately increase utilization of ambulatory
care services among undocumented safety-net patients and subsequently reduce avoidable ED
visits for ACSCs. After our quantitative analysis, the question arose of how, if at all, the
emergency care-seeking processes and behaviors of undocumented patients outlined in the
original theoretical framework would differ if they were to be examined through the lens of
patients’ ACSC status. We wondered if applying this lens would provide new perspective and
inform our growing understanding of the unique barriers to ambulatory care experienced by
undocumented safety-net ED patients with an ACSC and those seen for other conditions.
To answer this question, we conducted a QSA to reexamine emergency care-seeking
processes of undocumented patients from the perspective of patients’ ACSC status (study 3).
We created a subset of the principal data as well as a new analytic sample of all undocumented
patients interviewed between February 2019 and August 2022 (n=10). We classified patients’
ACSC status using medical record abstraction and according to AHRQ criteria. Interviews were
analyzed separately by patients’ ACSC status. Analytic memos were used to provide detailed
record of researchers’ thought processes and reflections throughout the iterative process.

111
Constant comparison was used to develop new themes related to patients’ ED care-seeking
processes and ambulatory care access. Through our QSA, we found that the ED care-seeking
pathways of undocumented patients differed by their ACSC status. For example,
undocumented patients’ with an ACSC preferred to seek ED care over ambulatory care based
on their perception that safety-net EDs offer better quality and more affordable health care
services than existing ambulatory care options. Additionally, undocumented patients seen for
other conditions described ED care-seeking pathways consistent with having access to
ambulatory care. Undocumented patients seen for other conditions described being referred to
the ED by an ambulatory care provider, which they perceived led to lower cost and more timely
ED care. We also found that exclusionary policies that limit undocumented patients’ ability to
access comprehensive health insurance influenced patient experiences of stigma and
discrimination when accessing health care services.
Recommendations
According to the Centers for Disease Control and Prevention, effective health promotion
programs should understand that health can be affected by multiple factors (individual, group,
and community, and physical, social, and political environments) and by the interaction
between those factors. Thus, recommendations for the implementation of study findings
presented in this dissertation will be discussed according to the levels of influence outlined in
the socioecological model. We begin by identifying factors of emergency care-seeking among
undocumented safety net patients at different levels (individual, interpersonal, community, and
society) and propose recommendations for developing approaches to reduce avoidable ED

112
utilization for an ACSC and promoting health among undocumented safety-net patients by
suggesting action at those levels.
Individual-Level Recommendations
Patient perceptions of ED care-seeking and ambulatory care are influenced by their
previous care-seeking experiences. Many patients we interviewed described being reluctant to
utilize existing ambulatory care offerings, including CHCs, because they perceived them to offer
lower-quality and higher-cost health care when compared to ED services. To address this, it is
recommended that educational interventions be conducted to improve undocumented safetynet patients’ awareness of high-quality, low-to-no-cost ambulatory care services available
throughout Los Angeles County. It is recommended that interventions focus on the
dissemination of information about both the importance of continuous ambulatory care for
health promotion and disease prevention, and the location, hours of operation, cost, contact
information, and list of services offered for available ambulatory care facilities. Priority should
be given to disseminating information about ambulatory care facilities that offer same-day
appointments and services during nontraditional hours, similar to EDs. Furthermore, special
attention should be given to highlighting facilities’ equipment and scheduling availability to
increase confidence among patients who may be reluctant to utilize ambulatory care services.
Interventions should be tailored to provide culturally competent information to undocumented
patient populations who are predominantly non-English speaking. Furthermore, interventions
should prioritize the discussion of patients’ rights to ambulatory care services and programs
regardless of documentation status to reduce fear and misinformation among undocumented
populations.

113
Interpersonal-Level Recommendations
To promote ambulatory care access among undocumented safety-net patients, it is
recommended that immigrant health advocates, providers, and researchers work with together
with community groups and partners to promote receipt of ambulatory care among patient
populations. Community-engaged research offers a unique opportunity for researchers to
engage members of the undocumented community in the development of programs and
interventions aimed at improving ambulatory care access among the population. Promoting
care coordination, such as using patient navigators and IBHS, offers a unique opportunity to
improve access to effective, efficient, and high-quality ambulatory care among safety-net
patients. The use of patient navigators in the safety-net setting has been associated with
improved patient outcomes, including management of ACSCs and clinical engagement among
patients with ACSCs. Research of care coordination efforts among undocumented immigrants in
the safety-net setting are notably missing. More research is needed to examine and promote
care coordination efforts among undocumented safety-net patients.
Community-Level Recommendations
We found that undocumented patients with an ACSC preferred to seek ED care over
ambulatory care based on their perception that safety-net EDs offer better quality and more
affordable health care services than existing ambulatory care options. To reduce ED
overcrowding, expenditure, and potentially avoidable ED visits for an ACSC, it is recommended
that local ambulatory care facilities and EDs serving predominantly safety-net patients work
together to improve the ED-to-ambulatory care pipeline. It is recommended that established
protocols for referring ED patients to ambulatory care be reexamined and tailored based on

114
patients’ ACSC status. Furthermore, it is recommended that greater efforts be made to
empanel undocumented patients who visit the ED to improve access to health services. It is also
recommended that additional financing be made available to local ambulatory care services to
improve scheduling and medical record system processes. Finally, wherever possible, state and
county funding should be channeled toward improving equipment availability at ambulatory
care facilities that serve predominantly undocumented safety-net patient populations.
Societal-Level Recommendations
Exclusionary policies create additional barriers to ambulatory care access among
undocumented immigrants. Reduced ambulatory care access has been associated with
increased avoidable safety-net ED utilization for ACSCs. Thus, to reduce avoidable ED visits for
ACSCs and promote health among undocumented patient populations, it is important that
health care providers, researchers, and advocates support the passage of regulations that
eliminate barriers to ambulatory care, including the expansion of insurance marketplace
participation for undocumented immigrants. In addition, it is not sufficient to offer health care
services to undocumented immigrants without the appropriate infrastructure to support their
health needs. As a result, to address existing shortages in primary care provider availability, it is
recommended that additional financial incentives be made to increase primary care provider
availability in areas where large undocumented patient populations reside throughout the
country, such as expansion of loan forgiveness programs, increased compensation, and tax
deductions. Moreover, given the minimal research that exists among undocumented patient
populations, it is also recommended that incentives be made available to promote immigrant
health research. Agencies should focus on the development of training grants aimed at

115
addressing immigrant-specific health care disparities. Finally, given their invaluable and distinct
skillset, bilingual providers and researchers from historically underrepresented minority groups
should receive incentives and compensation when joining these efforts.

116
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Abstract (if available)

Abstract Full title: A theoretical framework and mixed-methods investigation of document status as a social determinant of emergency department utilization at the largest urban safety-net hospital in Los Angeles, California. Abstract: In 2018, the United States Department of Homeland Security estimated that approximately 11.4 million undocumented immigrants were residing in the U.S. (Baker, 2021). Though limited research among the population exists, studies conducted to date have shown that undocumented immigrants are more likely to be low income and uninsured, as well as lack a usual source of care, use fewer preventive health services, and report poor health outcomes as compared to their U.S.-born and documented counterparts (Atkins et al., 2017; Atkins et al., 2018; Balakrishnan & Jordan, 2019; Cervantes et al., 2021; Cha et al., 2019; Guerrero et al., 2016; Torres & Waldinger, 2015). Due in large part to exclusion from public benefits, including the Affordable Care Act (ACA), undocumented immigrants’ ability to obtain comprehensive health insurance remains extremely limited. Barriers to care coverage leave many undocumented immigrants uninsured and dependent on safety-net health systems, particularly emergency departments (ED), when experiencing health care needs. Despite their unique care needs, little is known about undocumented patients’ ED care-seeking processes in the safety-net setting, including how and when patients decide when and where to seek safety-net ED care versus ambulatory care such as primary and specialty care. Furthermore, little is known about the association between documentation status and avoidable ED utilization for ambulatory care sensitive conditions (ACSCs). To address the knowledge gap, this dissertation conducts a comprehensive, mixed-methods investigation of documentation status as a social determinant of safety-net ED utilization at the largest public hospital in Los Angeles, California. Using a sequential design, each study informs and builds upon the others. Qualitative findings from study 1 inform the quantitative research question investigated in study 2, and results from studies 1 and 2 inform and contextualize the qualitative secondary analysis performed in study 3. Using a grounded theory approach, the first study develops a theoretical framework of safety-net ED care-seeking processes described by safety-net patients during semistructured interviews (n=25) and highlights distinct ED care-seeking processes described by undocumented patients. The second study uses multivariate logistic regression to investigate the association between documentation status and ED visit for an ACSC in a sample of n=129,834 safety-net ED patients at the largest public hospital in Los Angeles between 2016 and 2019. Results indicated that undocumented immigrants aged 26 to 64 had higher odds of ED utilization for an ACSC compared to U.S.-born individuals. Study 3 integrated results from studies 1 and 2 to inform a qualitative secondary analysis of the original theoretical framework. Results showed that undocumented patients whose ED visit pertained to an ACSC (n=5) described safety-net ED care-seeking processes distinct from those whose were seen for other conditions. The dissertation concludes by providing recommendations and future directions to address gaps in the literature and reduce existing inequities in ambulatory care access experienced by undocumented immigrants residing in Los Angeles.

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Asset Metadata

Creator Ramirez, Cynthia Nicole (author)

Core Title A theoretical framework and mixed-methods investigation of document status as a social determinant of emergency department utilization…

School Keck School of Medicine

Degree Doctor of Philosophy

Degree Program Preventive Medicine (Health Behavior)

Degree Conferral Date 2023-12

Publication Date 10/30/2023

Defense Date 09/29/2023

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag ambulatory care sensitive conditions (ACSCs),documentation status,emergency department utilization,OAI-PMH Harvest

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Unger, Jennifer (committee chair), Bluthenthal, Ricky (committee member), Burner, Elizabeth (committee member), Farias, Albert (committee member), Javier, Joyce (committee member), Kim, Sue (committee member)

Creator Email cnramire@usc.edu,cynthramire@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113761001

Unique identifier UC113761001

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Legacy Identifier etd-RamirezCyn-12436

Document Type Dissertation

Format theses (aat)

Rights Ramirez, Cynthia Nicole

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