A theoretical framework and mixed-methods investigation of documentation status as a social determinant of emergency care utilization in adult safety-net patients - PROJECT SUMMARY/ABSTRACT BACKGROUND: As a historically minoritized and marginalized population, undocumented immigrants residing in the US face unique and intersecting social and structural inequities in health care access and outcomes. Undocumented immigrants are significantly more likely to report limited access to health insurance coverage, less use of preventive health services, and worse health outcomes as compared to their documented counterparts. Due in-part to exclusionary policies limiting access to comprehensive health insurance coverage, many undocumented immigrants are left with little to no choice but to search for alternative care seeking strategies, including use of safety net emergency departments (EDs) for potentially preventable conditions when experiencing health needs. However, undocumented immigrants remain largely underrepresented in the emergency care utilization literature. ED utilization for ambulatory sensitive care conditions (ACSCs) - conditions for which good outpatient care and early intervention can prevent complications, hospitalization, or more severe disease – are a costly form of health care that have been associated with various social determinants of health, including lack of insurance, however, documentation status as a social determinant of ED utilization for ACSCs is notably missing in the health utilization literature. METHODS: I propose an in-depth investigation of documentation status as a social determinant of ED utilization for ACSCs and non-ACSC in the safety-net setting. In addition to studying the ED care seeking behaviors of adult safety-net patients by various demographic and clinical factors, I will also use project results to propose policy and program solutions for reducing inequities in care and access in the safety-net setting. To accomplish these objectives, I will pursue the following specific aims: 1) Use a traditional grounded theory approach to conduct n=25-30 qualitative interviews on various interpersonal, sociocultural, and structural influences of emergency care seeking behaviors in documented and undocumented adult patients; 2) Use a concatenated, county-wide administrative, billings, and claims dataset to identify demographic and clinical characteristics of potentially preventable vs. non-preventable emergency department utilization among documented and undocumented adult patients at an urban safety-net ED; and 3) Merge datasets from Specific Aims 1-2 and conduct a comprehensive mixed-methods analysis of how various clinical, interpersonal, sociocultural, and structural influences of emergency care seeking intersect, diverge, and converge among and within distinct case-comparison groups – including reason for admission and disposition, country of birth and primary language, and insurance type and housing status - in documented and undocumented adult patients at an urban, safety-net ED. RESULTS: By providing a comprehensive understanding of documentation status as a social determinant of ED utilization in the safety- net setting, this project will help identify the best immediate and long-term policy and program solutions for improving access to equitable, quality healthcare for documented and undocumented safety-net ED patients.
