Behavioral Health Needs of Newcomer Patients in a Pediatric Emergency Department

Behavioral Health Needs of Newcomer Patients in a Pediatric Emergency Department | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Behavioral Health Needs of Newcomer Patients in a Pediatric Emergency Department Kalyn Holmes, Emily Weinberger, Taylor McCormick, Erin Soares This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8810672/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Newcomers face multiple stressors impacting their wellbeing, including pre-existing psychiatric diagnoses and emerging concerns related to migration, which contribute to barriers accessing behavioral health and medical care. As such, they are more likely to seek care in emergency department (ED) settings than primary care and commonly present to safety-net institutions. Capitalizing on such systems and improving pathways to care can help reduce barriers and improve access to behavioral health care for this population. However, there is limited understanding of current behavioral health concerns and practices in EDs, particularly for the newcomer population. Methods: We conducted secondary analyses of deidentified data collected as part of routine practice at a safety-net hospital serving youth patients and their families who have recently arrived in the United States. We describe encounter-level clinical data for newcomer youth evaluated by an integrated psychology service in a pediatric ED setting. Results: Newcomer patients faced behavioral health concerns and social stressors that often were not their chief complaint. Additionally, about one-third of newcomer patients accepted referrals for follow-up care with this number dropping in Fall 2024. Conclusions: Findings highlight a need for tailored, trauma-informed care delivered in spaces commonly accessed by this population. Integrated psychology services in EDs show promise for identifying concerns and improving access to care for newcomer patients. Migrant stress and mental health integrated behavioral health hospital-based integrated psychology services safety-net hospital newcomer populations Figures Figure 1 Figure 2 Introduction Recently, the United States (U.S.) has experienced a significant influx of newcomer families fleeing poverty and violence in their countries of origin. Over the last 30 years, there has been a 50% increase in newcomer youth migrating to the U.S [ 1 ]. Individuals leave their birth countries for numerous reasons, often searching for safety and better opportunities, and receive a variety of designations which have important political and legal ramifications such as “asylum seeker,” “refugee,” and “migrant” [ 2 – 3 ]. The term “newcomer” is used in this paper to describe all immigrants regardless of official legal designation. Daily newcomer crossings at the U.S.-Mexico border hit record highs in 2023, with more than 2,230 newcomers crossing the border daily [ 4 ]. From 2020 to 2021, there was a nine-fold increase in unaccompanied minors arriving to the U.S. (15,381 versus 128,904, respectively), primarily originating from Central America [ 5 ]. Newcomer youth arriving to the U.S. face multiple stressors during migration which may impact their mental health and functioning [ 6 ]. Adverse experiences may include exposure to violence, hunger, and harm while traveling to the U.S. as well as post-migration acculturative stress due to factors such as community violence, xenophobia, and limited educational support [ 2 , 7 ]. Two-thirds of Latine newcomer youth have experienced at least one lifetime traumatic event, with over half of these events occurring in their country of origin and 40% occurring either during migration or since arriving to the U.S [ 8 ]. In a sample of 515 adults migrating from Honduras, El Salvador, and Guatemala in the 2018 “migrant caravan,” half of the participants migrated with families and children; over 90% endorsed pre-migration victimization including over 70% who experienced death threats and 67% who received threats of violence in their country of origin [ 9 ]. Chronic exposure to traumatic experiences and acculturative stress may contribute to elevated rates of depression, anxiety, eating disorders, substance misuse, and behavior problems [ 9 – 10 ]. Newcomer youth face barriers to accessing necessary medical and behavioral health care and community resources including language differences, lack of interpreters, fear of the disclosure process, bureaucratic obstacles (e.g., paperwork and registration systems), concerns about the cost of medical care, and limited trust in the medical system [ 2 , 11 , 12 ]. Moreover, many newcomer families face financial difficulties, lack of access to insurance, and fear of negative repercussions related to their immigration status [ 11 , 13 , 14 ]. Barriers to accessing behavioral health services include cultural stigma and treatment that is not culturally-responsive (e.g., services that are linguistically inappropriate or include interpretations of mental illness and distress that are incompatible with the patient’s culture) [ 14 ]. Thus, newcomer families are less likely to have an established primary care physician (PCP) and are instead more likely to seek care for both medical and behavioral health concerns in emergency department (ED) settings [ 13 , 15 ]. Although newcomer youth have similar medical acuity compared to general population controls, they have a significantly higher rate of ED visits [ 16 ]. Newcomer youth are more likely to present to the ED with their first mental health crisis compared to non-immigrant youth, with higher rates of ED visits among more recent newcomers, particularly those from Central America and Africa [ 16 ]. These findings underscore the need for tailored, culturally-responsive ED-based services to support this population [ 15 ]. Newcomer youth and families are also more likely to present to care at safety-net hospitals, facilities whose mission is to provide comprehensive care to all patients irrespective of immigration status, insurance, and ability to pay [ 11 , 17 ]. However, these systems are often strained due to high patient demand, financial limitations, and systemic challenges [ 11 ]. Given the disproportionately high rates of behavioral health problems and barriers to care for newcomer youth and families, it is vital to improve pathways to quality behavioral health care within these institutions. An ideal way to improve access to care is with the integrated behavioral health (IBH) model, which incorporates behavioral health providers into medical settings, often primary care, to facilitate timely and efficient access to services, normalize contact with behavioral health providers, and improve cross-discipline collaboration which can effectively address intersecting needs [ 18 – 20 ]. This approach is well-suited to identify and intervene on behavioral health needs of newcomer patients who may otherwise lack interest or access to mental health treatment, particularly as psychiatric symptoms may emerge post-migration [ 10 , 21 , 22 ]. The International Family Medicine Clinic at the University of Virginia Health System hosts an innovative model of integrated, culturally-responsive care for newcomer populations by providing services from family medicine, mental health, and psychiatry specialties to patients in primary care [ 22 ]. This approach has increased patient engagement with behavioral health services [ 22 , 23 ]. While this model holds great promise for replication, a recent systematic review on integrated care models for newcomer populations suggests these services are seldom implemented and universal mental health screening is not standard practice in medical settings serving newcomer patients [ 24 ]. Most IBH services are in outpatient settings [ 25 ], which differ significantly from EDs, where newcomers often receive care [ 15 , 26 ]. However, there is a dearth of research on the application of IBH in pediatric ED settings despite 13% of all pediatric ED visits being mental health-related, particularly for newcomer youth who are more likely to present to EDs with a first time mental health crisis than their non-newcomer counterparts [ 16 , 27 ]. INSTITUTION hosts the Pediatric Emergency Department Integrated Psychology (PEDIPsy) service, a unique model of IBH services in a pediatric ED, further described below in Methods. Patients receive brief psychological evaluations, psychoeducation, brief interventions (e.g., mindfulness, cognitive behavioral therapy skills, relaxation training, dialectical behavioral therapy skills), and referrals to ongoing behavioral health treatment. Standard work includes universal suicide screening for patients 12 years and older via the Ask Suicide-Screening Questions (ASQ) tool administered by nursing staff, and PEDIPsy conducts safety assessments for all patients screened at risk for suicide [ 28 ]. PEDIPsy also routinely screens for health-related social needs using the Accountable Health Communities (AHC) 10-question screener and refers patients to internal care navigators as indicated [ 29 ]. PEDIPsy psychologists also liaise with and facilitate transfers to the Psychiatric Emergency Services (PES) department at INSTITUTION for acute psychiatric presentations [ 30 ]. One recent evaluation of PEDIPsy suggested a mixed impact for a general pediatric ED sample, though the study was limited by sample size, outcomes assessed, and clinical specificity [ 31 ]. To our knowledge, there are no existing studies evaluating behavioral health needs and utilization patterns among newcomer youth in ED settings. This critical knowledge gap warrants greater attention to better meet the distinct needs of this population. Research regarding the treatment of patients by this unique service at INSTITUTION can provide valuable insight into the current concerns for newcomer youth presenting to EDs in addition to the interventions and referrals implemented to address these concerns. The current study will (1) characterize the psychological and social needs of newcomer youth presenting to the pediatric ED, (2) describe the interventions and referrals currently implemented for these patients, and (3) describe the newcomer population evaluated by the PEDIPsy service. Methods Participants Data was examined for 62 unique youth patients (ages 2 to 19) from a total of 67 encounters evaluated by INSTITUTION’S PEDIPsy service between October 2022 and April 2025 who were identified as newcomers based on self-reported country of origin during hospital registration. Of note, INSTITUTION stopped asking new patients to disclose country of origin in February 2025, although implementation of this discontinuation was inconsistent. Six countries of origin were reported: Colombia, El Salvador, Guatemala, Honduras, Nicaragua, and Venezuela. The most common countries of origin were Venezuela (47.2%) and Colombia (23.6%; Table 1 ). Patients were on average 13.7 years old ( SD = 4.8) and the majority identified as Hispanic, Latine, and/or Spanish origin (95.2%) cisgender females (75.8%). Medicaid was the most common insurance provider (43.5%) at the time of data extraction. Unfortunately, researchers were limited by institutional data extraction procedures and thus unable to obtain insurance status at the time of the encounter. Prior to the January 2025 expansion of Medicaid eligibility to include all children and pregnant people regardless of immigration status, the majority of newcomers presented as self-pay with the option to enroll in the Colorado Indigent Care Program (CICP), which provides discounted health care services to low-income patients and families who are not Medicaid-eligible. Table 1 Demographic Information n % M ( SD ) Race and Ethnicity Hispanic, Latine, or Spanish Origin 59 95.2 Other 41 66.1 White or Caucasian 21 33.9 Sex Female 47 75.8 Male 15 24.2 Country of Origin Venezuela 34 47.2 Colombia 17 23.6 El Salvador 3 4.2 Guatemala 3 4.2 Honduras 3 4.2 Nicaragua 2 2.8 Age 13.73 (4.78) Note. No additional races, ethnicities, sex and/or gender identities were reported by this sample. Data was initially collected as part of routine hospital processes. Transgender and cisgender identity were not collected. As such, our sex variable may include individuals who identify as cisgender, transgender, and/or nonbinary. Patient self-description for those who selected the “other” race and ethnicity option was not available. Measures PEDIPsy Encounter Variables Clinical data were queried from PEDIPsy encounter notes which included standardized sections completed by providers. “Consult reason” was defined as the behavioral, emotional, or substance use concern(s) for which psychology staff evaluated a patient, either by medical staff consults or proactive chart review, selected from a drop-down menu. In the “Intervention” section, providers selected which brief evidence-based treatments they provided at bedside from a drop-down menu (e.g., relaxation skills, psychoeducation, emotional support, connection to follow-up care). The “Follow-up plan” denotes the patient’s disposition, including whether a patient accepted or declined a referral or resource(s). These drop-down menus included an “other” free-response option for each variable. The consult reason and intervention sections are multiple response whereas follow-up plan allows for only one response. Additional Variables To analyze trends over time, we examined frequency data by month and year of encounter date. We also examined the chief complaint associated with the index ED visit and patient’s insurance provider documented at the time of data extraction (May 2025). We assessed whether a patient returned to the pediatric ED within 30 days and one year of their index encounter. We also assessed the total number of pediatric ED visits within one year [ 32 ]. Patient demographic data, including race, ethnicity, country of origin, age at index ED visit, and sex reported in the Electronic Health Record (EHR), were also examined. Procedure Setting and System of Care INSTITUTION. INSTITUTION is a comprehensive safety-net hospital system in a sanctuary city for newcomers serving under-resourced patients across the lifespan. In 2023, it was estimated that newcomers accounted for approximately 10% of all adult and pediatric ED visits at INSTITUTION. The continuum of care at INSTITUTION is diverse, including services addressing medical, behavioral health, substance use, and social welfare concerns in inpatient, primary care, outpatient, emergency, and urgent care settings. Pediatric Emergency Department. We examined data from INSTITUTION’S PEDIPsy service. The service is staffed by licensed clinical psychologists and psychology trainees (pre-doctoral interns and post-doctoral fellows) who provide behavioral health care to youth and families. PEDIPsy providers tailor their evaluations and interventions based on presenting concern and developmental stage of patients. While PEDIPsy does not conduct universal or routine screenings of newcomer patients, the service is often consulted to address the behavioral health needs of this population. PEDIPsy conducted an average of 70.5 patient visits per month during the study period with 3% of patients evaluated between October 2022 and April 2025 being known newcomer patients. Patients are identified for this service by consultation from medical providers and proactive chart review by PEDIPsy providers. Data Source Data was collected from the encounter notes documented per routine practice in Epic, the institution’s EHR. The dataset was deidentified and maintained in a password-protected database on a secure server which only approved researchers had access to. This study was approved as exempt from review by the Colorado Multiple Institutional Review Board (COMIRB). Data Analyses Secondary analyses of deidentified data were conducted. This study was exploratory in nature and used univariate and bivariate quantitative approaches to examine frequencies, means, and possible relationships between study variables (consult reason, intervention, follow-up plan) and secondary variables (month and year evaluated, chief complaint, demographic information, insurance status). We followed established guidelines for exploring data including visual examination and univariate and bivariate analyses of study variables and other data [ 33 ]. Results Multiple clinical variables including chief complaint, pediatric ED return visits, and insurance type were examined (Table 2 ). Abdominal pain (11.9%), chest pain (7.5%), and headache (7.5%) were the most common chief complaints; 6% of newcomers had a chief complaint related to emotional or behavioral health concerns (e.g., anxiety or behavior problems). The number of newcomer patients evaluated by PEDIPsy began increasing in Fall 2023 with spikes in January 2024 and November 2024 (Figs. 1 and 2 ). The number of newcomer encounters decreased in January 2025 and remained relatively low after that time despite a steady increase in non-newcomer encounters during the same period. About one-quarter (24.2%) of newcomer patients returned to the pediatric ED within one year, and 33.3% of those who returned were evaluated by PEDIPsy during at least one of their return visits. Almost half (46.7%) of those who returned (11.3% of total sample) did so within 30 days of their index encounter. Medicaid was the most common insurance provider (43.5%) followed by uninsured (35.5%) and the CICP, a payment assistance program (21.0%). Table 2 Other Pediatric ED Encounter and Return Data n % M ( SD ) Ten most common chief complaints Abdominal pain 8 11.9 Chest pain 5 7.5 Headache 5 7.5 Fever 3 4.5 Abdominal pain -pregnant 2 3.0 Anxiety 2 3.0 Behavior problem 2 3.0 Pregnancy problem 2 3.0 Seizure 2 3.0 Assault victim 2 3.0 Insurance status at time of data extraction* Medicaid 27 43.5 Self-Pay 22 35.5 Colorado Indigent Care Program 13 21.0 Return to pediatric ED Overall 15 24.2 <30 days following index peds ED encounter 7 11.3 Number of returns to peds ED 2 (1.13) Note. Insurance data reflects patient insurance status at time of data extraction (March 2025), not necessarily insurance status at time of index peds ED encounter. In January 2025, Medicaid eligibility expanded to include all children and pregnant people regardless of immigration status. Intervention type frequency data are shown in the first section of Table 3 . Most newcomers received psychoeducation (89.6%) and emotional support (85.1%) during their PEDIPsy encounter. More than half were taught coping skills (65.8%) and close to half (46.3%) were connected to follow-up care. While consult data showed only 7.5% ( n = 5) of newcomer patients were considered at risk for suicide, 11.9% ( n = 8) received safety planning as an intervention during their PEDIPsy evaluation. More than a third (35.8%) of patients declined a referral and 37.3% of patients accepted a referral to either outpatient specialty mental health (29.9%) or primary care clinics (7.5%; Table 3 ). The “other” follow-up plan was selected for 22.4% of newcomer patients; the most common “other” free-responses included providing information about community-based, culturally-informed resources and the local crisis line. The rate at which newcomer patients accepted referrals, on average, remained steady over the past two years, but the rate at which newcomer patients declined a referral increased in Fall 2024 (Fig. 1 ). Table 3 Consult reason, interventions, and follow-up plan frequency data n % Interventions Psychoeducation 60 89.6 Emotional Support 57 85.1 Discussion of coping skills 44 65.7 Connection to follow-up care 31 46.3 Parenting training 9 13.4 Relaxation training 8 11.9 Safety planning 8 11.9 Brief behavioral therapy 6 9.0 Other 6 9.0 Motivational Interviewing 3 4.5 Substance counseling 2 3.0 Follow-up Plan None, patient declined 24 35.8 Outpatient specialty mental health clinic 20 29.9 Other 11 16.4 Outpatient primary care clinic 5 7.5 Transfer to psychiatric or inpatient unit 4 6.0 Not sure 3 4.5 Consult reason Other 32 47.8 Anxiety 19 28.4 Depression 7 10.5 Somatic Symptoms 5 7.5 Suicide Risk 5 7.5 History of Behavioral Health Concern 4 6.0 History of Trauma 3 4.5 Altered Mental Status 2 3.0 Disposition Planning 2 3.0 Adjustment Related Stress 1 1.5 Grief 1 1.5 Non-alcohol substance use concern 1 1.5 Note. Themes in "other" consult reason included pregnancy/young parent concerns, victim of violence or bullying, and social stressors. Themes in "other" intervention included consulting with other departments/providers and providing patient with paper resources. Themes in "other" follow-up plan included providing patient with community-based support resources (e.g., Servicios de la Raza, Colorado Crisis Line). Consult reasons not selected for newcomer patients but in the drop-down menu included: alcohol use disorder, behavior concern, caregiver support, disordered eating, eligibility for involuntary treatment, and violence risk. Interventions not indicated for newcomer patients but in the drop-down menu included: medication management and initiation of mental health hold/involuntary treatment. Consult reason frequency data suggests that the “other” free-response option was most often selected (47.8%; Table 3 ). Common free-responses included pregnancy/parenting concerns, social stressors, and issues related to violence, harassment, or bullying. The next most common consult reasons were anxiety (28.4%) and depression (10.5%). The least common consult reasons were adjustment-related stress, grief, and non-alcohol substance use concern (1.5% each). The number of consult reasons indicated per encounter ranged between one and three with an average of 1.22 ( SD = 0.55). The three most common consult reasons over time are demonstrated in Fig. 2 . While consult rates for depression have remained steady over time, consults for anxiety appear cyclical in nature with numbers decreasing to zero for multiple months in a row during the summer and increasing over the fall and winter months. Discussion Many newcomer patients are balancing co-occurring medical, behavioral health, and social needs which are not immediately apparent based solely on their ED chief complaint. As such, newcomer patients might benefit from access to routine behavioral health and social needs screenings. While implementation of screenings may increase the considerable burden on EDs and emergency medicine providers [ 34 , 35 ], IBH providers embedded in EDs are an ideal resource to provide these services. Integrated providers are an asset for implementing routine preventative screenings and collaborating with medical staff on evaluation, intervention, and disposition planning for patients with primary behavioral health concerns. Only about one-third of newcomer patients accepted referrals for follow-up care. Our results suggest an increase in patients declining referrals, particularly during Fall 2024, preceding a sudden drop in the overall number of newcomer patients evaluated by the PEDIPsy service. This finding could be partially related to a change in hospital registration procedures to stop collecting country of origin in February 2025, although this was inconsistently implemented. It may also reflect newcomer patients’ disinterest in ongoing behavioral health care, fear about negative repercussions and discrimination related to recent policy changes, shifting political climates, and/or fear of increased immigration law enforcement presence in previously protected treatment settings [ 36 ]. Considering this, newcomer patients may be more hesitant to present to EDs or accept referrals for follow-up care if they are asked to share identifying information. Nearly a quarter of newcomer patients evaluated by PEDIPsy returned to the ED within one year of their index visit. Approximately half of pediatric ED revisits occurred within 30 days of their index visit and many returned more than once within the year. This is consistent with previous research showing newcomer patients frequently access health care via EDs and suggests EDs may be the only place to identify and address medical and behavioral health care needs for many newcomers [ 15 , 16 ]. Of note, baseline pediatric ED revisits rates for a non-newcomer population at our institution are 16.2% of the total population within 30 days and 28.4% within 1 year of index encounter. As such, the newcomer population at INSTITUTION appears to return to the pediatric ED at similar rates to the non-newcomer population. Consistent with the PEDIPsy service model, most newcomer patients received psychoeducation, emotional support, and teaching about coping skills during their evaluation with a psychology provider in the ED. The number of safety plans completed was higher than the number of newcomer patients flagged for suicide risk based on consult reason. It is likely that PEDIPsy providers discovered previously unknown or unreported suicidality during their evaluation, which includes a safety assessment as part of standard work and provision of appropriate safety and discharge planning interventions in response and escalation to higher levels of care when indicated (6% of study population transferred to higher level of care following safety assessment, as indicated in Table 3 ). Embedded psychology services may be particularly well-suited to identify and address suicidality which may otherwise be missed in the ED setting when it is not a patient’s chief complaint or revealed during routine suicide screening. The most common consult reasons for newcomer patients evaluated by PEDIPsy fell in the “other” category (e.g., pregnancy/parenting concerns, social stressors, and issues related to violence, harassment, or bullying), anxiety, and depression. Additionally, many PEDIPsy evaluations included multiple consult reasons. This suggests that newcomer youth and families likely face a range of co-occurring stressors; systems serving newcomer patients might benefit from screening for these issues and developing materials for patients highlighting available resources and services for these common consult reasons. The low rate of adjustment-related concerns may be an artifact of this consult reason being added to the pre-built drop-down menu in November 2024. It could also suggest that this population does not conceptualize their stress as related to adjustment. Specifically, this may reflect newcomer youth and families experiencing both a sense of relief following migrating to the U.S. and ongoing stress related to obtaining necessary social supports and navigating complex systems [ 37 ]. Overall, the sample was largely homogeneous, specifically of majority Hispanic, Latine, and/or Spanish origin and female identifying, suggesting this population may be more likely to have a PEDIPsy consult and may be more willing to access health care [ 38 ]. More intentional outreach and engagement approaches may improve accessibility for newcomer patients who identify as other sex and gender identities. The diverse age range (2 to 19 years old) in this sample demonstrates that pediatric ED-based interventions aimed at addressing newcomer mental health concerns should take a developmental approach to evaluation and treatment. Limitations and Future Directions This study used real-world clinical data collected as part of standard practice in a safety-net pediatric ED allowing for insight into current practices, strengths, and gaps in existing services to inform broader translational science. However, some limitations should be considered. Firstly, inclusion in this study was determined using self-reported country of origin collected during the standard hospital registration process. Some patients may be unwilling to disclose their country of origin to hospital staff due to possible fear of bias and/or negative repercussions. Thus, it is possible this dataset lacks important perspectives of patients who did not disclose this information. Future studies could use anonymized and/or community-based recruitment processes to gather the perspectives of families experiencing anxiety or stress related to discussing their immigration status with medical and behavioral health providers. Focusing on the newcomer experiences of individuals migrating from South and Central America is necessary given the dearth of research with this population as well as increased bias and discrimination against this population. Due to the size and homogeneity of the sample, findings should be interpreted and generalized with caution as they may not represent the experiences of the greater newcomer population in the U.S. Future studies should consider examining data from newcomer populations across a variety of geographic regions. Unfortunately, institutional data extraction methods only allow for capturing insurance status at the time of data extraction which is likely different than patient insurance status during their index ED encounter. Additionally, major changes to Medicaid eligibility to include all children and pregnant patients regardless of immigration status occurred in January 2025, presumably impacting the insurance status at the time of our data extraction in March 2025. A patient’s insurance status at the time of the encounter likely impacts their interest in – or ability to – accept a referral to follow-up care. Future research should further investigate the relationship between insurance status and openness to receiving referrals for follow-up behavioral health care. Finally, future studies might include control trials examining medical and behavioral health outcomes for newcomer patients evaluated by IBH services. Future researchers should consider investigating qualitative aims such as newcomer patients’ perspectives on the accessibility and availability of current outpatient and community-based services available. Future investigations should incorporate key community and system-based partners to understand and reduce barriers to establishing safe spaces for newcomer patients to access necessary resources and to develop programs aimed at supporting this population. Conclusions Overall, newcomer youth seeking care in EDs often experience anxiety, depression, and social stressors which may not be immediately apparent based on chief complaint. Additionally, many newcomer youth may hesitate to present to institutions previously viewed as safe havens or to accept behavioral health referrals or community resources due to fear of discrimination and/or deportation in these spaces [ 36 ]. As such, systems of care and the providers therein should adapt their approaches to identify and address the multiple stressors faced by this population while maintaining their privacy and safety. Further, it will become increasingly necessary to creatively address the social stressors, anxiety, and depression experienced by newcomer patients outside of these systems. Existing approaches to screening, intervention, and referrals should be adapted for use in the community which could include surveys that can be completed via phone or pen and paper and educational materials which can be provided quickly and covertly, as needed. Integrated psychology services, such as the PEDIPsy service detailed in this paper, are ideally situated to implement screenings, brief interventions, and connection to care tailored to meet the needs of newcomer youth and families and to increase access to behavioral health care for families who might not otherwise interact with this specialty. Providing access to resources or brief bedside interventions could help bridge the gaps in medical, behavioral, and social health care impacting this population. Declarations Ethics approval and consent to participate : This study received ethical approval and exemption status from the Colorado Multiple Institutional Review Board (approval #25-1033) on 13-Jun-2025. This is an IRB-approved retrospective study, all patient information was de-identified and patient consent was not required. Patient data will not be shared with third parties. Requirement for informed consent to participate was waived by the Colorado Multiple Institutional Review Board. Consent for publication : Not applicable. Competing interests : The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article. Author Contribution KH contributed to the conceptualization, methodology, formal analysis, writing, visualization, and project administration of this study. EW contributed to the conceptualization, methodology, writing, and literature review of this study. TM contributed to the supervision, review, and editing of this study. KH contributed to the conceptualization, methodology, review, and editing of this study. Acknowledgements: Not applicable. 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Ramanuj P, Ferenchik E, Docherty M, Spaeth-Rublee B, Pincus HA. Evolving models of integrated behavioral health and primary care. Curr Psychiatry Rep. 2019;21:1–12. Chisholm CD, Dornfeld AM, Nelson DR, Cordell WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med. 2001;38(2):146–51. Bommersbach TJ, McKean AJ, Olfson M, Rhee TG. National trends in mental health–related emergency department visits among youth, 2011–2020. JAMA. 2023;329(17):1469–77. Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein,D. L., … Joshi, P. (2012). Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of Pediatrics & Adolescent Medicine, 166(12), 1170–1176. Billioux A, Verlander K, Anthony S, Alley D. Standardized screening for health-related social needs in clinical settings: The accountable health communities screening tool. Discussion Paper: National Academy of Medicine. Washington, DC. (2017). Simpson SA, Monroe C. Implementing and evaluating a standard of care for clinical evaluations in emergency psychiatry. J Emerg Med. 2018;55(4):522–9. Casher GA, Sutton B, Roosevelt G, Simpson SA. Evaluation of an integrated psychology service in a pediatric emergency department and urgent care. Pediatr Emerg Care. 2022;38(2):e697–702. Schwartz, S., Michel, J., Brown, E., Bullard, M., Chan, C. Y. M., Doolittle, J., …Kumar, A. Assessing the impact of an innovate behavioral health clinic: a retrospective cohort study. BMC psychiatry, (2025): 25(1), 1–9. Fife D. The eight steps of data analysis: A graphical framework to promote sound statistical analysis. Perspect Psychol Sci. 2020;15(4):1054–75. Bernstein SL, Haukoos JS. Public health, prevention, and emergency medicine: a critical juxtaposition. Acad Emerg Med, (2008): 15(2). Kelen GD. Public health initiatives in the emergency department: not so good for the public health? Acad Emerg Med, (2008).15(2). Blackburn CC, Rico M, Knight L, Lee M, Hernandez J. Examining the Presence of Border Patrol Agents in Hospitals in South Texas. J Immigr Minor Health. 2025;27(3):424–30. Shea M, Wong YJ. A two-way street: immigrants’ mental health challenges, resilience, and contributions. One Earth. 2022;5(8):845–8. Thompson AE, Anisimowicz Y, Miedema B, Hogg W, Wodchis WP, Aubrey Bassler K. The influence of gender and other patient characteristics on health care-seeking behaviour: a QUALICOPC study. BMC Fam Pract. 2016;17:1–7. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8810672","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":598326094,"identity":"c2d8eaa4-35aa-4f90-8981-b95e3012f7df","order_by":0,"name":"Kalyn Holmes","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYBACCQbmBiB1gIEPxPvAdiCBCC2MEC1sQJJxBslamHmI0SLZfrBNuoDhjhyb2OHDn23K7uTxNzAf+/gFjxZpnsQ26RkMz4zZpNPSpHPOPSuWOMCWPFsGjxY5BqAWHobDQDLHjDm37XBiwwEeY2YJfFr4H8K05H/+bAnUMp+QFmkJhC0M0oxALRuAWhg/4PP+jIfN1jwGh0F+MZPsOXc4ceNhtmRmPDoYJM4nH7zNU3FYjl86+fGHH2WHE+cdbz7M+AOfHgYGFgkGA2Q+MyiC8GthxnQ4IVtGwSgYBaNgZAEAGtxNSrTUCmUAAAAASUVORK5CYII=","orcid":"","institution":"Denver Health Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Kalyn","middleName":"","lastName":"Holmes","suffix":""},{"id":598326100,"identity":"c6240d6c-e3b7-40fb-8e41-c500f86298e7","order_by":1,"name":"Emily Weinberger","email":"","orcid":"","institution":"Denver Health Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Emily","middleName":"","lastName":"Weinberger","suffix":""},{"id":598326102,"identity":"1c0f7a29-cfc2-4cd5-95b8-326a6656663b","order_by":2,"name":"Taylor McCormick","email":"","orcid":"","institution":"Denver Health Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Taylor","middleName":"","lastName":"McCormick","suffix":""},{"id":598326103,"identity":"e85f10e7-29f1-485f-a756-d65d4cc2751a","order_by":3,"name":"Erin Soares","email":"","orcid":"","institution":"Denver Health Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Erin","middleName":"","lastName":"Soares","suffix":""}],"badges":[],"createdAt":"2026-02-06 20:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8810672/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8810672/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12939-026-02860-9","type":"published","date":"2026-04-24T15:59:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":104400997,"identity":"f994b3e6-d6fa-4c3f-9bda-e2892b8840ee","added_by":"auto","created_at":"2026-03-11 12:11:39","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":329773,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFrequency of top two follow-up plans compared to newcomer pediatric ED encounters over time\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8810672/v1/f2f6c72871dc756f8cbd02b1.jpeg"},{"id":103837682,"identity":"6c05168b-e605-438e-9c8f-d6773f41f5ca","added_by":"auto","created_at":"2026-03-03 14:17:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":202339,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eTop three consult reasons compared to newcomer and overall pediatric ED encounters over time\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8810672/v1/8f88320a3cccc2377697b824.png"},{"id":107928037,"identity":"dc9a6ca3-91ac-49a7-9e69-4f59c8f03c1b","added_by":"auto","created_at":"2026-04-27 16:06:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":824035,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8810672/v1/5e89e587-98b8-453a-bc74-00577ddbb83a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Behavioral Health Needs of Newcomer Patients in a Pediatric Emergency Department","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRecently, the United States (U.S.) has experienced a significant influx of newcomer families fleeing poverty and violence in their countries of origin. Over the last 30 years, there has been a 50% increase in newcomer youth migrating to the U.S [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Individuals leave their birth countries for numerous reasons, often searching for safety and better opportunities, and receive a variety of designations which have important political and legal ramifications such as \u0026ldquo;asylum seeker,\u0026rdquo; \u0026ldquo;refugee,\u0026rdquo; and \u0026ldquo;migrant\u0026rdquo; [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The term \u0026ldquo;newcomer\u0026rdquo; is used in this paper to describe all immigrants regardless of official legal designation. Daily newcomer crossings at the U.S.-Mexico border hit record highs in 2023, with more than 2,230 newcomers crossing the border daily [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. From 2020 to 2021, there was a nine-fold increase in unaccompanied minors arriving to the U.S. (15,381 versus 128,904, respectively), primarily originating from Central America [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNewcomer youth arriving to the U.S. face multiple stressors during migration which may impact their mental health and functioning [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Adverse experiences may include exposure to violence, hunger, and harm while traveling to the U.S. as well as post-migration acculturative stress due to factors such as community violence, xenophobia, and limited educational support [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Two-thirds of Latine newcomer youth have experienced at least one lifetime traumatic event, with over half of these events occurring in their country of origin and 40% occurring either during migration or since arriving to the U.S [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In a sample of 515 adults migrating from Honduras, El Salvador, and Guatemala in the 2018 \u0026ldquo;migrant caravan,\u0026rdquo; half of the participants migrated with families and children; over 90% endorsed pre-migration victimization including over 70% who experienced death threats and 67% who received threats of violence in their country of origin [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Chronic exposure to traumatic experiences and acculturative stress may contribute to elevated rates of depression, anxiety, eating disorders, substance misuse, and behavior problems [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNewcomer youth face barriers to accessing necessary medical and behavioral health care and community resources including language differences, lack of interpreters, fear of the disclosure process, bureaucratic obstacles (e.g., paperwork and registration systems), concerns about the cost of medical care, and limited trust in the medical system [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, many newcomer families face financial difficulties, lack of access to insurance, and fear of negative repercussions related to their immigration status [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Barriers to accessing behavioral health services include cultural stigma and treatment that is not culturally-responsive (e.g., services that are linguistically inappropriate or include interpretations of mental illness and distress that are incompatible with the patient\u0026rsquo;s culture) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Thus, newcomer families are less likely to have an established primary care physician (PCP) and are instead more likely to seek care for both medical and behavioral health concerns in emergency department (ED) settings [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although newcomer youth have similar medical acuity compared to general population controls, they have a significantly higher rate of ED visits [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Newcomer youth are more likely to present to the ED with their first mental health crisis compared to non-immigrant youth, with higher rates of ED visits among more recent newcomers, particularly those from Central America and Africa [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These findings underscore the need for tailored, culturally-responsive ED-based services to support this population [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Newcomer youth and families are also more likely to present to care at safety-net hospitals, facilities whose mission is to provide comprehensive care to all patients irrespective of immigration status, insurance, and ability to pay [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, these systems are often strained due to high patient demand, financial limitations, and systemic challenges [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Given the disproportionately high rates of behavioral health problems and barriers to care for newcomer youth and families, it is vital to improve pathways to quality behavioral health care within these institutions.\u003c/p\u003e \u003cp\u003eAn ideal way to improve access to care is with the integrated behavioral health (IBH) model, which incorporates behavioral health providers into medical settings, often primary care, to facilitate timely and efficient access to services, normalize contact with behavioral health providers, and improve cross-discipline collaboration which can effectively address intersecting needs [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This approach is well-suited to identify and intervene on behavioral health needs of newcomer patients who may otherwise lack interest or access to mental health treatment, particularly as psychiatric symptoms may emerge post-migration [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The International Family Medicine Clinic at the University of Virginia Health System hosts an innovative model of integrated, culturally-responsive care for newcomer populations by providing services from family medicine, mental health, and psychiatry specialties to patients in primary care [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This approach has increased patient engagement with behavioral health services [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. While this model holds great promise for replication, a recent systematic review on integrated care models for newcomer populations suggests these services are seldom implemented and universal mental health screening is not standard practice in medical settings serving newcomer patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Most IBH services are in outpatient settings [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], which differ significantly from EDs, where newcomers often receive care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, there is a dearth of research on the application of IBH in pediatric ED settings despite 13% of all pediatric ED visits being mental health-related, particularly for newcomer youth who are more likely to present to EDs with a first time mental health crisis than their non-newcomer counterparts [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eINSTITUTION hosts the Pediatric Emergency Department Integrated Psychology (PEDIPsy) service, a unique model of IBH services in a pediatric ED, further described below in Methods. Patients receive brief psychological evaluations, psychoeducation, brief interventions (e.g., mindfulness, cognitive behavioral therapy skills, relaxation training, dialectical behavioral therapy skills), and referrals to ongoing behavioral health treatment. Standard work includes universal suicide screening for patients 12 years and older via the Ask Suicide-Screening Questions (ASQ) tool administered by nursing staff, and PEDIPsy conducts safety assessments for all patients screened at risk for suicide [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. PEDIPsy also routinely screens for health-related social needs using the Accountable Health Communities (AHC) 10-question screener and refers patients to internal care navigators as indicated [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. PEDIPsy psychologists also liaise with and facilitate transfers to the Psychiatric Emergency Services (PES) department at INSTITUTION for acute psychiatric presentations [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. One recent evaluation of PEDIPsy suggested a mixed impact for a general pediatric ED sample, though the study was limited by sample size, outcomes assessed, and clinical specificity [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. To our knowledge, there are no existing studies evaluating behavioral health needs and utilization patterns among newcomer youth in ED settings.\u003c/p\u003e \u003cp\u003eThis critical knowledge gap warrants greater attention to better meet the distinct needs of this population. Research regarding the treatment of patients by this unique service at INSTITUTION can provide valuable insight into the current concerns for newcomer youth presenting to EDs in addition to the interventions and referrals implemented to address these concerns. The current study will (1) characterize the psychological and social needs of newcomer youth presenting to the pediatric ED, (2) describe the interventions and referrals currently implemented for these patients, and (3) describe the newcomer population evaluated by the PEDIPsy service.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eData was examined for 62 unique youth patients (ages 2 to 19) from a total of 67 encounters evaluated by INSTITUTION\u0026rsquo;S PEDIPsy service between October 2022 and April 2025 who were identified as newcomers based on self-reported country of origin during hospital registration. Of note, INSTITUTION stopped asking new patients to disclose country of origin in February 2025, although implementation of this discontinuation was inconsistent. Six countries of origin were reported: Colombia, El Salvador, Guatemala, Honduras, Nicaragua, and Venezuela. The most common countries of origin were Venezuela (47.2%) and Colombia (23.6%; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients were on average 13.7 years old (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.8) and the majority identified as Hispanic, Latine, and/or Spanish origin (95.2%) cisgender females (75.8%). Medicaid was the most common insurance provider (43.5%) at the time of data extraction. Unfortunately, researchers were limited by institutional data extraction procedures and thus unable to obtain insurance status at the time of the encounter. Prior to the January 2025 expansion of Medicaid eligibility to include all children and pregnant people regardless of immigration status, the majority of newcomers presented as self-pay with the option to enroll in the Colorado Indigent Care Program (CICP), which provides discounted health care services to low-income patients and families who are not Medicaid-eligible.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDemographic Information\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e(\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace and Ethnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic, Latine, or Spanish Origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite or Caucasian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry of Origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenezuela\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColombia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEl Salvador\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuatemala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHonduras\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNicaragua\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.73 (4.78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote.\u003c/em\u003e No additional races, ethnicities, sex and/or gender identities were reported by this sample. Data was initially collected as part of routine hospital processes. Transgender and cisgender identity were not collected. As such, our sex variable may include individuals who identify as cisgender, transgender, and/or nonbinary. Patient self-description for those who selected the \u0026ldquo;other\u0026rdquo; race and ethnicity option was not available.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePEDIPsy Encounter Variables\u003c/h2\u003e \u003cp\u003eClinical data were queried from PEDIPsy encounter notes which included standardized sections completed by providers. \u0026ldquo;Consult reason\u0026rdquo; was defined as the behavioral, emotional, or substance use concern(s) for which psychology staff evaluated a patient, either by medical staff consults or proactive chart review, selected from a drop-down menu. In the \u0026ldquo;Intervention\u0026rdquo; section, providers selected which brief evidence-based treatments they provided at bedside from a drop-down menu (e.g., relaxation skills, psychoeducation, emotional support, connection to follow-up care). The \u0026ldquo;Follow-up plan\u0026rdquo; denotes the patient\u0026rsquo;s disposition, including whether a patient accepted or declined a referral or resource(s). These drop-down menus included an \u0026ldquo;other\u0026rdquo; free-response option for each variable. The consult reason and intervention sections are multiple response whereas follow-up plan allows for only one response.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAdditional Variables\u003c/h3\u003e\n\u003cp\u003eTo analyze trends over time, we examined frequency data by month and year of encounter date. We also examined the chief complaint associated with the index ED visit and patient\u0026rsquo;s insurance provider documented at the time of data extraction (May 2025). We assessed whether a patient returned to the pediatric ED within 30 days and one year of their index encounter. We also assessed the total number of pediatric ED visits within one year [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Patient demographic data, including race, ethnicity, country of origin, age at index ED visit, and sex reported in the Electronic Health Record (EHR), were also examined.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSetting and System of Care\u003c/h2\u003e \u003cp\u003e \u003cb\u003eINSTITUTION.\u003c/b\u003e INSTITUTION is a comprehensive safety-net hospital system in a sanctuary city for newcomers serving under-resourced patients across the lifespan. In 2023, it was estimated that newcomers accounted for approximately 10% of all adult and pediatric ED visits at INSTITUTION. The continuum of care at INSTITUTION is diverse, including services addressing medical, behavioral health, substance use, and social welfare concerns in inpatient, primary care, outpatient, emergency, and urgent care settings.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePediatric Emergency Department.\u003c/b\u003e We examined data from INSTITUTION\u0026rsquo;S PEDIPsy service. The service is staffed by licensed clinical psychologists and psychology trainees (pre-doctoral interns and post-doctoral fellows) who provide behavioral health care to youth and families. PEDIPsy providers tailor their evaluations and interventions based on presenting concern and developmental stage of patients. While PEDIPsy does not conduct universal or routine screenings of newcomer patients, the service is often consulted to address the behavioral health needs of this population. PEDIPsy conducted an average of 70.5 patient visits per month during the study period with 3% of patients evaluated between October 2022 and April 2025 being known newcomer patients. Patients are identified for this service by consultation from medical providers and proactive chart review by PEDIPsy providers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Source\u003c/h2\u003e \u003cp\u003eData was collected from the encounter notes documented per routine practice in Epic, the institution\u0026rsquo;s EHR. The dataset was deidentified and maintained in a password-protected database on a secure server which only approved researchers had access to. This study was approved as exempt from review by the Colorado Multiple Institutional Review Board (COMIRB).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData Analyses\u003c/h2\u003e \u003cp\u003eSecondary analyses of deidentified data were conducted. This study was exploratory in nature and used univariate and bivariate quantitative approaches to examine frequencies, means, and possible relationships between study variables (consult reason, intervention, follow-up plan) and secondary variables (month and year evaluated, chief complaint, demographic information, insurance status). We followed established guidelines for exploring data including visual examination and univariate and bivariate analyses of study variables and other data [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eMultiple clinical variables including chief complaint, pediatric ED return visits, and insurance type were examined (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Abdominal pain (11.9%), chest pain (7.5%), and headache (7.5%) were the most common chief complaints; 6% of newcomers had a chief complaint related to emotional or behavioral health concerns (e.g., anxiety or behavior problems). The number of newcomer patients evaluated by PEDIPsy began increasing in Fall 2023 with spikes in January 2024 and November 2024 (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The number of newcomer encounters decreased in January 2025 and remained relatively low after that time despite a steady increase in non-newcomer encounters during the same period. About one-quarter (24.2%) of newcomer patients returned to the pediatric ED within one year, and 33.3% of those who returned were evaluated by PEDIPsy during at least one of their return visits. Almost half (46.7%) of those who returned (11.3% of total sample) did so within 30 days of their index encounter. Medicaid was the most common insurance provider (43.5%) followed by uninsured (35.5%) and the CICP, a payment assistance program (21.0%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eOther Pediatric ED Encounter and Return Data\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e(\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTen most common chief complaints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain -pregnant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnancy problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssault victim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsurance status at time of data extraction*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-Pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColorado Indigent Care Program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReturn to pediatric ED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;30 days following index peds ED encounter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of returns to peds ED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (1.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote.\u003c/em\u003e Insurance data reflects patient insurance status at time of data extraction (March 2025), not necessarily insurance status at time of index peds ED encounter. In January 2025, Medicaid eligibility expanded to include all children and pregnant people regardless of immigration status.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIntervention type frequency data are shown in the first section of Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Most newcomers received psychoeducation (89.6%) and emotional support (85.1%) during their PEDIPsy encounter. More than half were taught coping skills (65.8%) and close to half (46.3%) were connected to follow-up care. While consult data showed only 7.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5) of newcomer patients were considered at risk for suicide, 11.9% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8) received safety planning as an intervention during their PEDIPsy evaluation. More than a third (35.8%) of patients declined a referral and 37.3% of patients accepted a referral to either outpatient specialty mental health (29.9%) or primary care clinics (7.5%; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The \u0026ldquo;other\u0026rdquo; follow-up plan was selected for 22.4% of newcomer patients; the most common \u0026ldquo;other\u0026rdquo; free-responses included providing information about community-based, culturally-informed resources and the local crisis line. The rate at which newcomer patients accepted referrals, on average, remained steady over the past two years, but the rate at which newcomer patients declined a referral increased in Fall 2024 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eConsult reason, interventions, and follow-up plan frequency data\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychoeducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscussion of coping skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConnection to follow-up care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenting training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelaxation training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSafety planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrief behavioral therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotivational Interviewing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstance counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up Plan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone, patient declined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutpatient specialty mental health clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutpatient primary care clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfer to psychiatric or inpatient unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot sure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsult reason\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomatic Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuicide Risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of Behavioral Health Concern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of Trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAltered Mental Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisposition Planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjustment Related Stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-alcohol substance use concern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote.\u003c/em\u003e Themes in \"other\" consult reason included pregnancy/young parent concerns, victim of violence or bullying, and social stressors. Themes in \"other\" intervention included consulting with other departments/providers and providing patient with paper resources. Themes in \"other\" follow-up plan included providing patient with community-based support resources (e.g., Servicios de la Raza, Colorado Crisis Line). Consult reasons not selected for newcomer patients but in the drop-down menu included: alcohol use disorder, behavior concern, caregiver support, disordered eating, eligibility for involuntary treatment, and violence risk. Interventions not indicated for newcomer patients but in the drop-down menu included: medication management and initiation of mental health hold/involuntary treatment.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eConsult reason frequency data suggests that the \u0026ldquo;other\u0026rdquo; free-response option was most often selected (47.8%; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Common free-responses included pregnancy/parenting concerns, social stressors, and issues related to violence, harassment, or bullying. The next most common consult reasons were anxiety (28.4%) and depression (10.5%). The least common consult reasons were adjustment-related stress, grief, and non-alcohol substance use concern (1.5% each). The number of consult reasons indicated per encounter ranged between one and three with an average of 1.22 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.55). The three most common consult reasons over time are demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. While consult rates for depression have remained steady over time, consults for anxiety appear cyclical in nature with numbers decreasing to zero for multiple months in a row during the summer and increasing over the fall and winter months.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMany newcomer patients are balancing co-occurring medical, behavioral health, and social needs which are not immediately apparent based solely on their ED chief complaint. As such, newcomer patients might benefit from access to routine behavioral health and social needs screenings. While implementation of screenings may increase the considerable burden on EDs and emergency medicine providers [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], IBH providers embedded in EDs are an ideal resource to provide these services. Integrated providers are an asset for implementing routine preventative screenings and collaborating with medical staff on evaluation, intervention, and disposition planning for patients with primary behavioral health concerns.\u003c/p\u003e \u003cp\u003eOnly about one-third of newcomer patients accepted referrals for follow-up care. Our results suggest an increase in patients declining referrals, particularly during Fall 2024, preceding a sudden drop in the overall number of newcomer patients evaluated by the PEDIPsy service. This finding could be partially related to a change in hospital registration procedures to stop collecting country of origin in February 2025, although this was inconsistently implemented. It may also reflect newcomer patients\u0026rsquo; disinterest in ongoing behavioral health care, fear about negative repercussions and discrimination related to recent policy changes, shifting political climates, and/or fear of increased immigration law enforcement presence in previously protected treatment settings [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Considering this, newcomer patients may be more hesitant to present to EDs or accept referrals for follow-up care if they are asked to share identifying information.\u003c/p\u003e \u003cp\u003eNearly a quarter of newcomer patients evaluated by PEDIPsy returned to the ED within one year of their index visit. Approximately half of pediatric ED revisits occurred within 30 days of their index visit and many returned more than once within the year. This is consistent with previous research showing newcomer patients frequently access health care via EDs and suggests EDs may be the only place to identify and address medical and behavioral health care needs for many newcomers [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Of note, baseline pediatric ED revisits rates for a non-newcomer population at our institution are 16.2% of the total population within 30 days and 28.4% within 1 year of index encounter. As such, the newcomer population at INSTITUTION appears to return to the pediatric ED at similar rates to the non-newcomer population.\u003c/p\u003e \u003cp\u003eConsistent with the PEDIPsy service model, most newcomer patients received psychoeducation, emotional support, and teaching about coping skills during their evaluation with a psychology provider in the ED. The number of safety plans completed was higher than the number of newcomer patients flagged for suicide risk based on consult reason. It is likely that PEDIPsy providers discovered previously unknown or unreported suicidality during their evaluation, which includes a safety assessment as part of standard work and provision of appropriate safety and discharge planning interventions in response and escalation to higher levels of care when indicated (6% of study population transferred to higher level of care following safety assessment, as indicated in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Embedded psychology services may be particularly well-suited to identify and address suicidality which may otherwise be missed in the ED setting when it is not a patient\u0026rsquo;s chief complaint or revealed during routine suicide screening.\u003c/p\u003e \u003cp\u003eThe most common consult reasons for newcomer patients evaluated by PEDIPsy fell in the \u0026ldquo;other\u0026rdquo; category (e.g., pregnancy/parenting concerns, social stressors, and issues related to violence, harassment, or bullying), anxiety, and depression. Additionally, many PEDIPsy evaluations included multiple consult reasons. This suggests that newcomer youth and families likely face a range of co-occurring stressors; systems serving newcomer patients might benefit from screening for these issues and developing materials for patients highlighting available resources and services for these common consult reasons. The low rate of adjustment-related concerns may be an artifact of this consult reason being added to the pre-built drop-down menu in November 2024. It could also suggest that this population does not conceptualize their stress as related to adjustment. Specifically, this may reflect newcomer youth and families experiencing both a sense of relief following migrating to the U.S. and ongoing stress related to obtaining necessary social supports and navigating complex systems [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the sample was largely homogeneous, specifically of majority Hispanic, Latine, and/or Spanish origin and female identifying, suggesting this population may be more likely to have a PEDIPsy consult and may be more willing to access health care [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. More intentional outreach and engagement approaches may improve accessibility for newcomer patients who identify as other sex and gender identities. The diverse age range (2 to 19 years old) in this sample demonstrates that pediatric ED-based interventions aimed at addressing newcomer mental health concerns should take a developmental approach to evaluation and treatment.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eThis study used real-world clinical data collected as part of standard practice in a safety-net pediatric ED allowing for insight into current practices, strengths, and gaps in existing services to inform broader translational science. However, some limitations should be considered. Firstly, inclusion in this study was determined using self-reported country of origin collected during the standard hospital registration process. Some patients may be unwilling to disclose their country of origin to hospital staff due to possible fear of bias and/or negative repercussions. Thus, it is possible this dataset lacks important perspectives of patients who did not disclose this information. Future studies could use anonymized and/or community-based recruitment processes to gather the perspectives of families experiencing anxiety or stress related to discussing their immigration status with medical and behavioral health providers.\u003c/p\u003e \u003cp\u003eFocusing on the newcomer experiences of individuals migrating from South and Central America is necessary given the dearth of research with this population as well as increased bias and discrimination against this population. Due to the size and homogeneity of the sample, findings should be interpreted and generalized with caution as they may not represent the experiences of the greater newcomer population in the U.S. Future studies should consider examining data from newcomer populations across a variety of geographic regions.\u003c/p\u003e \u003cp\u003eUnfortunately, institutional data extraction methods only allow for capturing insurance status at the time of data extraction which is likely different than patient insurance status during their index ED encounter. Additionally, major changes to Medicaid eligibility to include all children and pregnant patients regardless of immigration status occurred in January 2025, presumably impacting the insurance status at the time of our data extraction in March 2025. A patient\u0026rsquo;s insurance status at the time of the encounter likely impacts their interest in \u0026ndash; or ability to \u0026ndash; accept a referral to follow-up care. Future research should further investigate the relationship between insurance status and openness to receiving referrals for follow-up behavioral health care.\u003c/p\u003e \u003cp\u003eFinally, future studies might include control trials examining medical and behavioral health outcomes for newcomer patients evaluated by IBH services. Future researchers should consider investigating qualitative aims such as newcomer patients\u0026rsquo; perspectives on the accessibility and availability of current outpatient and community-based services available. Future investigations should incorporate key community and system-based partners to understand and reduce barriers to establishing safe spaces for newcomer patients to access necessary resources and to develop programs aimed at supporting this population.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOverall, newcomer youth seeking care in EDs often experience anxiety, depression, and social stressors which may not be immediately apparent based on chief complaint. Additionally, many newcomer youth may hesitate to present to institutions previously viewed as safe havens or to accept behavioral health referrals or community resources due to fear of discrimination and/or deportation in these spaces [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. As such, systems of care and the providers therein should adapt their approaches to identify and address the multiple stressors faced by this population while maintaining their privacy and safety. Further, it will become increasingly necessary to creatively address the social stressors, anxiety, and depression experienced by newcomer patients outside of these systems. Existing approaches to screening, intervention, and referrals should be adapted for use in the community which could include surveys that can be completed via phone or pen and paper and educational materials which can be provided quickly and covertly, as needed. Integrated psychology services, such as the PEDIPsy service detailed in this paper, are ideally situated to implement screenings, brief interventions, and connection to care tailored to meet the needs of newcomer youth and families and to increase access to behavioral health care for families who might not otherwise interact with this specialty. Providing access to resources or brief bedside interventions could help bridge the gaps in medical, behavioral, and social health care impacting this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEthics approval and consent to participate\u003c/span\u003e:\u003c/strong\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e This study received ethical approval and exemption status from the Colorado Multiple Institutional Review Board (approval #25-1033) on 13-Jun-2025. This is an IRB-approved retrospective study, all patient information was de-identified and patient consent was not required. Patient data will not be shared with third parties. Requirement for informed consent to participate was waived by the Colorado Multiple Institutional Review Board.\u003c/span\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eConsent for publication\u003c/span\u003e:\u003c/strong\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNot applicable.\u003c/span\u003e \u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCompeting interests\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/span\u003e \u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe author(s) received no financial support for the research, authorship, and/or publication of this article.\u003c/span\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKH contributed to the conceptualization, methodology, formal analysis, writing, visualization, and project administration of this study. EW contributed to the conceptualization, methodology, writing, and literature review of this study. TM contributed to the supervision, review, and editing of this study. KH contributed to the conceptualization, methodology, review, and editing of this study.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNot applicable.\u003c/span\u003e \u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated during and/or analyzed during the current study are not publicly available due to use of patient data in the context of a retrospective study but are available from the corresponding author, pending hospital research leadership approval.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eInternational Organization for Migration (IOM). 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BMC Public Health, (2024): 24(1), 963.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalami B, Salma J, Hegadoren K. Access and utilization of mental health services for immigrants and refugees: Perspectives of immigrant service providers. Int J Ment Health Nurs. 2019;28(1):152\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbrams AH, Leonard J, Brewer SE, Young J, Adelgais KM. Emergency care utilization by refugee children compared to controls: A statewide database analysis. PloSOne, (2025): 20(2), e0318248.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaunders NR, Gill PJ, Holder L, Vigod S, Kurdyak P, Gandhi S, Guttmann A. Use of the emergency department as a first point of contact for mental health care by immigrant youth in Canada: a population-based study. CMAJ, (2018): 190(40), E1183-E1191.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWinkelman TN, Vickery KD. Refining the definition of US safety-net hospitals to improve population health. JAMA Netw Open. 2019;2(8):e198562\u0026ndash;198562.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Psychological Association. (2013). Integrated health Care. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.apa.org/health/integrated-health-care\u003c/span\u003e\u003cspan address=\"https://www.apa.org/health/integrated-health-care\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed 20 May 2025].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller-Matero LR, Dykuis KE, Albujoq K, Martens K, Fuller BS, Robinson V, Willens DE. Benefits of integrated behavioral health services: The physician perspective. Families Syst Health. 2016;34(1):51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProm MC, Canelos V, Fernandez PJ, Barnett G, Gordon K, Pace CM, C. A., Ng LC. Implementation of integrated behavioral health care in a large medical center: benefits, challenges, and recommendations. J Behav Health Serv Res. 2021;48(3):346\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChu T, Keller AS, Rasmussen A. Effects of post-migration factors on PTSD outcomes among immigrant survivors of political violence. J Immigr Minor Health. 2013;15:890\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaniel KE, Blackstone SR, Tan JS, Merkel RL, Hauck FR, Allen CW. Integrated model of primary and mental healthcare for the refugee population served by an academic medical centre. Family Med Community Health. 2023;11(2):e002038.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitchell D, Olson A, Randolph N. The impact of warm handoffs on patient engagement with behavioral health services in primary care. J Rural Mental Health. 2022;46(2):82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbu Suhaiban H, Grasser LR, Javanbakht A. Mental health of refugees and torture survivors: a critical review of prevalence, predictors, and integrated care. Int J Environ Res Public Health. 2019;16(13):2309.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamanuj P, Ferenchik E, Docherty M, Spaeth-Rublee B, Pincus HA. Evolving models of integrated behavioral health and primary care. Curr Psychiatry Rep. 2019;21:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChisholm CD, Dornfeld AM, Nelson DR, Cordell WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med. 2001;38(2):146\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBommersbach TJ, McKean AJ, Olfson M, Rhee TG. National trends in mental health\u0026ndash;related emergency department visits among youth, 2011\u0026ndash;2020. JAMA. 2023;329(17):1469\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein,D. L., \u0026hellip; Joshi, P. (2012). Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of Pediatrics \u0026amp; Adolescent Medicine, 166(12), 1170\u0026ndash;1176.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBillioux A, Verlander K, Anthony S, Alley D. Standardized screening for health-related social needs in clinical settings: The accountable health communities screening tool. Discussion Paper: National Academy of Medicine. Washington, DC. (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimpson SA, Monroe C. Implementing and evaluating a standard of care for clinical evaluations in emergency psychiatry. J Emerg Med. 2018;55(4):522\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasher GA, Sutton B, Roosevelt G, Simpson SA. Evaluation of an integrated psychology service in a pediatric emergency department and urgent care. Pediatr Emerg Care. 2022;38(2):e697\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwartz, S., Michel, J., Brown, E., Bullard, M., Chan, C. Y. M., Doolittle, J., \u0026hellip;Kumar, A. Assessing the impact of an innovate behavioral health clinic: a retrospective cohort study. BMC psychiatry, (2025): 25(1), 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFife D. The eight steps of data analysis: A graphical framework to promote sound statistical analysis. Perspect Psychol Sci. 2020;15(4):1054\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernstein SL, Haukoos JS. Public health, prevention, and emergency medicine: a critical juxtaposition. Acad Emerg Med, (2008): 15(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelen GD. Public health initiatives in the emergency department: not so good for the public health? Acad Emerg Med, (2008).15(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlackburn CC, Rico M, Knight L, Lee M, Hernandez J. Examining the Presence of Border Patrol Agents in Hospitals in South Texas. J Immigr Minor Health. 2025;27(3):424\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShea M, Wong YJ. A two-way street: immigrants\u0026rsquo; mental health challenges, resilience, and contributions. One Earth. 2022;5(8):845\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson AE, Anisimowicz Y, Miedema B, Hogg W, Wodchis WP, Aubrey Bassler K. The influence of gender and other patient characteristics on health care-seeking behaviour: a QUALICOPC study. BMC Fam Pract. 2016;17:1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Migrant stress and mental health, integrated behavioral health, hospital-based integrated psychology services, safety-net hospital, newcomer populations","lastPublishedDoi":"10.21203/rs.3.rs-8810672/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8810672/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Newcomers face multiple stressors impacting their wellbeing, including pre-existing psychiatric diagnoses and emerging concerns related to migration, which contribute to barriers accessing behavioral health and medical care. As such, they are more likely to seek care in emergency department (ED) settings than primary care and commonly present to safety-net institutions. Capitalizing on such systems and improving pathways to care can help reduce barriers and improve access to behavioral health care for this population. However, there is limited understanding of current behavioral health concerns and practices in EDs, particularly for the newcomer population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe conducted secondary analyses of deidentified data collected as part of routine practice at a safety-net hospital serving youth patients and their families who have recently arrived in the United States. We describe encounter-level clinical data for newcomer youth evaluated by an integrated psychology service in a pediatric ED setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eNewcomer patients faced behavioral health concerns and social stressors that often were not their chief complaint. Additionally, about one-third of newcomer patients accepted referrals for follow-up care with this number dropping in Fall 2024.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Findings highlight a need for tailored, trauma-informed care delivered in spaces commonly accessed by this population. Integrated psychology services in EDs show promise for identifying concerns and improving access to care for newcomer patients.\u003c/p\u003e","manuscriptTitle":"Behavioral Health Needs of Newcomer Patients in a Pediatric Emergency Department","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-03 14:17:43","doi":"10.21203/rs.3.rs-8810672/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-20T19:06:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-20T18:48:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T20:28:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127725228987771929249518369858192094765","date":"2026-02-27T18:51:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49671994829454286061768124535461324008","date":"2026-02-23T15:12:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-23T13:13:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-11T12:13:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-11T12:12:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2026-02-06T20:19:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0286229c-9ef7-4c96-92e2-b51933c640b7","owner":[],"postedDate":"March 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:04:33+00:00","versionOfRecord":{"articleIdentity":"rs-8810672","link":"https://doi.org/10.1186/s12939-026-02860-9","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2026-04-24 15:59:33","publishedOnDateReadable":"April 24th, 2026"},"versionCreatedAt":"2026-03-03 14:17:43","video":"","vorDoi":"10.1186/s12939-026-02860-9","vorDoiUrl":"https://doi.org/10.1186/s12939-026-02860-9","workflowStages":[]},"version":"v1","identity":"rs-8810672","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8810672","identity":"rs-8810672","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}