ABSTRACT
Undocumented migrants are a vulnerable population that experiences numerous unique challenges that prevent them from adequately accessing healthcare, leading to many easily preventable diseases and medical outcomes. Misconceptions about the necessity of preventative care, fear of deportation, as well as language barriers discourage undocumented migrants from seeking care. Undocumented migrants disproportionately work manual labor jobs in economic sectors like agriculture, meaning that these challenges compound and exacerbate the likelihood of chronic or lifestyle disease.

Compared to all the other US states, California has the highest population of immigrants. Los Angeles County is estimated to be home to around 1 million undocumented migrants, with concentrations of these migrants residing in ethnic enclaves at or around downtown LA. Many are uninsured or underinsured, ultimately resulting in avoidable complications relating to health and well-being.

The Los Angeles Mobile Clinic Project (LAMCP) hopes to combat this problem. Modeled on the existing UCLA mobile project for the unhoused, LAMCP hopes to provide free, accessible, and safe care to undocumented migrants in Los Angeles. LAMCP targets this goal by establishing two mobile clinics in Los Angeles, each stocked with medical supplies and multilingual staff prepared to administer free, preventative care to those who need it. These mobile clinics will travel around LA, with routes published several weeks to months in advance of the formal opening. Route destinations will be focused on areas with high concentrations of undocumented migrants. At each destination, a seminar will be given on the best practices for leading healthy lifestyles while navigating being undocumented. To facilitate this education and the care administered, four primary staff members would manage each clinic: a nurse practitioner, two registered nurses, and finally a care coordinator. A project manager will also be hired to oversee both clinics and LAMCP. As the program grows, partnerships with larger organizations like the National Association of Free & Charitable Clinics (NAFC) will help garner a broader platform and reach with the intervention.

With LAMCP, the overall health of the undocumented migrant population in LA is expected to improve. There is a special necessity for the program today in the context of the aftermath of the COVID-19 pandemic, which has excessively affected low-income and minority communities, particularly those without access to healthcare. LAMCP will positively affect many groups of people including those who receive care and those who help fund it.

PROBLEM STATEMENT
Background and Significance

An abundance of factors act as barriers to undocumented migrants which causes them to struggle greatly when trying to secure proper medical care. Another preventative factor is the fear of deportation. Some undocumented migrants cannot safely go to any facility that requires private information (including hospitals), because this information can be used against the migrant to target and even deport them. Furthermore, language barriers can be a major hindrance to healthcare access because many undocumented migrants are not fluent or proficient in English, so they cannot communicate effectively with a sizable population of healthcare workers. A final barrier lies in the lack of education on preventative healthcare. Many undocumented migrants are uninformed or misinformed about the nature and necessity of less severe healthcare interventions such as yearly checkups and behaviors that can minimize the risk of lifestyle diseases like diabetes or lung cancer.

Of all 50 states in the USA, California has the highest population of immigrants with about 11 million throughout. Of those, upwards of 4 million live in Los Angeles alone with the total number of undocumented migrants being around 1 million residents. Almost half of these undocumented migrants are uninsured and/or their yearly income lies below 200% of the poverty line, making access to proper healthcare extremely difficult. Many of the undocumented migrants also live in ethnic enclaves near and around downtown Los Angeles. As the city with the highest concentration of undocumented migrants, LAMCP will initially be implemented to combat the healthcare crisis in Los Angeles.

Literature Review and Previous Interventions

Despite an apparent positive difference in life expectancy between Hispanic immigrants and their children, factors such as lower income and uninsurance or underinsurance have a degenerative effect on undocumented migrant health. Namely, practices of waiting to go to a doctor or not going to a doctor caused by underinsurance are correlated with worse health outcomes. For this reason, states such as California have already expanded their Medicaid (Medi-Cal) programs to include coverage for undocumented migrants under the age of 25. However, recognizing that this neither applies to much of the undocumented population nor does it guarantee a decrease in negative health outcomes, LAMCP draws on interventions that affect other vulnerable groups. Specifically, the Mobile Clinic Project (MCP) at UCLA has been designed to effectively and efficiently dispense healthcare education and information, allowing for unhoused people to intervene in their own situations. This project used food accommodations and a published route to draw community members and provide education and nutrition.

Target Population

LAMCP will primarily serve undocumented migrants in Los Angeles, but it will not exclusively serve that group. LAMCP will extend care to whoever needs it, regardless of immigration status. The program has the capacity to serve those who need preventative care, but not those requiring immediate emergency assistance. It will primarily focus on administering care like vaccinations or medication to young children and teenagers aged 0-17. It will also provide preventative care for other complications to older working migrants aged 18-50. However, lunchtime seminars will be more relevant to a wider range of age migrants that includes those more elderly, focused towards all age groups from 0-80.

Key Stakeholders

LAMCP will have a conglomerate of stakeholders, perhaps the most necessary being the undocumented migrants who serve as the patients. As stakeholders with high interest but low power, this group of stakeholders will want the program to flourish and provide care, but will not have much say in how the program runs. Another group of essential stakeholders in the intervention is the workforce hired. The collection of employees holds a high interest in LAMCP, but the amount of power differs between positions. Nurses and care coordinators will be a cardinal part of the intervention through the care they administer and advice they provide on further medical treatment to the patients, but they will have medium-high power in how LAMCP runs. The project also requires a project manager, who will have high power in the operation of the intervention. The project manager will aim to see the success of LAMCP. A prominent organization and stakeholder in the program is the NAFC. NAFC would have medium interest in LAMCP specifically due to all the other free clinics they oversee, but the party would have high power in guiding operations and maximizing success. Lastly, employers of undocumented migrants can be considered a more peripheral stakeholder to LAMCP and maintain medium interest along with low power. Industries such as fashion and agriculture rely heavily on undocumented migrants’ labor, so employers need healthy workers for the industries to maintain sustainability.

PROGRAM DESCRIPTION
Program Goals, Objectives, and Justifications

Program Goal: The goal of LAMCP is to help undocumented migrants get healthcare. Currently, most undocumented migrants are unable to get preventative healthcare for a number of reasons including being uninsured or having a fear of getting deported. LAMCP will establish 2 free mobile clinics that will focus on providing more safe, accessible services for predominantly Latinx undocumented migrants in Los Angeles. LAMCP will also focus on education and raising awareness of healthcare.

Objective 1: The first objective is to establish clinics to increase undocumented peoples’ access to safe and effective healthcare. Clinics must be registered and licensed before beginning to administer care. The first step to establishing clinics (after appropriate funding has been secured) is to purchase suitable vehicles like an RV and the medical supplies that will need to be stocked inside of them. Secondly, the clinics require multilingual staff and volunteers, especially people fluent in both English and Spanish, to work and volunteer at the clinics.

Objective 2: One year after opening, LAMCP plans to have completed at least 2500 visits. As a new program, most people will still hold doubts about the safety and privacy of the project. By advertising the clinics in underserved LA communities, showcasing the seminars, and establishing easy access, more trust will slowly be established. As the project progresses, a partnership with the NAFC will help introduce the project to a larger platform with a more extensive reach, boosting the number of visits received.

Objective 3: One year after opening, LAMCP will have given seminars to 6000 different undocumented immigrants, educating the local community on the importance of maintaining their health and the methods to do so. The patients and attendees will also learn how to access more intensive care that the clinics cannot provide, if necessary. The primary method of reaching this goal is by hosting lunchtime seminars in workplaces in the service sectors with heavy undocumented immigrant populations. In these seminars, free lunches will be provided to all attendees as they are educated on topics relating to preventative healthcare or leading a healthy lifestyle. The secondary way to educate migrants is during patient visits, when a care coordinator will let the patient know about safe clinics or other healthcare facilities where they can receive follow-up treatment LAMCP cannot provide. After either seminars or appointments, patients will be asked for feedback about whether they might refer a friend to the clinics, how to improve service, and what other healthcare topics they would like to know about. Over time, the clinic can incorporate this community feedback to specify and improve its efficacy. 

Theoretical Framework 

Our program is designed with the Donabedian model in mind. The seven parts of this model are efficacy, effectiveness, efficiency, equity, optimality, acceptability, and legitimacy. In accordance with that framework, LAMCP takes steps to ensure that the structure, process, and outcomes of health care each meet the level of quality expected by the program. This program also follows the guidance of Andersen’s Behavioral Model of Health to take into account and plan accordingly for how predisposing factors, enabling factors, and needs each lead to access to health services or lack thereof. By understanding the reasons why the target community may or may not seek Long Term Services & Supports, the project will better connect with the patients. These connections are integral to the clinic as it becomes more equipped to provide for the patients once their motives are acknowledged. Finally, the Health Belief Model also guides the program. This model focuses on patient perceptions that relate to access to care. Particularly, LAMCP aims to emphasize the perceived severity of not receiving regular care and explain the long-term adverse outcomes that may result from this. The intervention also breaks down perceived barriers to care by offering support, building trust, and explaining options to patients in need. 

Key Strategies and Activities

To implement the main goal of helping undocumented migrants get healthcare, LAMCP plans to start by hiring a project manager to oversee the operations of LAMCP and ensure its success. As mobile clinics are set up, resources and staff will be secured, including RVs, medical tools, and multilingual staff. For each clinic, the staff will include a nurse practitioner, two nurses, and a healthcare coordinator. Healthcare coordinators will host educational sessions daily in which they will educate the community on how to live a healthy lifestyle on a limited budget. Additionally, while being treated, the nurses will educate patients on where to reach further specialized healthcare facilities and medicine. To incentivize the sessions, Free lunch will be offered for the people who come and participate. Additionally, the clinics, their scheduled stops, and these sessions will be advertised through posted fliers, pamphlets, and online advertising around LA. After establishing LAMCP as a reliable clinic, a partnership with the NAFC will help the project branch out further and help more people. LAMCP wishes to make its patients feel secure, so the clinics plan to use patients’ first, middle (if applicable), and last names and an assigned ID number to identify each patient and their information. This will help the clinic to keep a record of a patient's medical history within the clinic without excluding undocumented immigrants from accessing resources.

Implementation Plan

Upon receiving the grant money, potential employees who are interested in working in LAMCP will undergo the interview process.  Employees must meet certain criteria such as speaking Spanish and having a minimum of two years of experience in their work. They must also express cultural fluency, the quality of being flexible and accommodating of different cultures. To ensure maximum trust and connection with clients, it is integral that employees are open, respectful, and sensitive to their specific needs. The clinic will also require equipment and resources to run. The clinic will operate using RVs to guarantee versatility and accessibility to a wide range of patients. After securing the grant money, the project will begin with the purchase of the clinic vehicles. Then, schedules and routes will be created based on which areas are categorized as high risk for lacking preventative care. They will be centered around the day jobs many undocumented migrants hold, including areas of agricultural, domestic, and textile work. LAMCP would like to provide the most convenient times and places for potential patients. High-quality medical equipment is also needed to provide high-quality services. Medical equipment will be acquired from larger, nearby hospitals. By partnering with hospitals, the project gains access to more resources, and the more established hospitals can reach a wider audience. The clinic will also need extensive publicity and exposure in the media, which will be achieved by partnerships with local organizations and larger nonprofit organizations such as the NAFC. Then, services and education will begin to be administered to the community. Community members will be given the opportunity to attend short lunchtime classes hosted by the healthcare coordinator. Attendees will be provided a free, nutritious meal as they sit in and listen. The clinic will also employ specialized systems to protect patients’ anonymity. Each of the patients will have an individualized ID number to easily access medical information without exposing their identity. This information can include medical history, familial history, and career details. Sensitive elements of patient data will also be encrypted to provide another layer of protection. Another essential component of the program is patient feedback. Direct patient feedback and opinions will help improve the quality of the clinic and care.

DISCUSSION
Importance

With LAMCP, thousands of at risk undocumented migrants will receive the proper healthcare that they need and deserve. The wicked nature of undocumented immigrants’ lack of access to healthcare means that any solution must make considerations for the numerous obstacles that non-citizens face. Overall, a staggeringly high percentage of undocumented people and documented children with undocumented parent(s) lack health insurance compared to the general population. Unfortunately, numerous other barriers exist as well. Undocumented immigrants see doctors for routine visits less often, putting them at a higher risk for disease and sickness. This happens as a result of lack of transportation, time to schedule a visit, or fear. They also have language barriers for which family interpreters are insufficient. This is important to the overall health of the undocumented migrant population of LA. Over time, as the program grows and word spreads, the reach will increase and nonprofit intervention will see patient population increase. The COVID-19 pandemic disproportionately affected marginalized communities, many of which have not fully recovered and are facing the effects of inadequate access to healthcare. LAMCP will help administer necessary care for all groups still feeling the effects of the pandemic and other health issues.

Who Should Care?

Undocumented migrants are the main beneficiaries of the project. LAMCP aims to remove any barriers that may prevent them from receiving the healthcare and long term services they require. In order to work in labor intensive jobs, migrant workers require resources to maintain their well-being. Employers of such workers would also benefit from the assistance the clinic can offer. In order for their businesses and companies to thrive, employers are in need of healthy employees. Oftentimes, employers cannot provide health insurance to their workers who are undocumented migrants. A clinic that focuses on these workers will incentivize employers to prioritize their employees’ health more. Medical professionals who work in the field would also share an interest as the clinic provides an opportunity to cater to a previously inaccessible population. Physicians often do not have the opportunity to aid undocumented migrants because they are ineligible for health insurance in the United States. The clinic would help remove the burden of inaccessibility for many of the migrant workers in LA. Although LAMCP concentrates on undocumented migrants, low-income workers are also a priority. Services will be accessible to these families as well, ensuring medical expenses will not deter them from medical aid.

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