Integration of Waiting Room “Know Your Rights” Education into Medical Care of Immigrant Patients in a Federally Qualified Health Center: A Case Study

Background: Federally qualified health centers (FQHCs) are implementing innovative interventions to address heightened anxieties of immigrant patients amid changing immigration policies. Purpose: To describe the integration of “Know Your Rights” legal rights education in clinic waiting rooms of an FQHC in Los Angeles, California. Methods: This is a qualitative study using key informant interviews, direct field observations, and document review. Results: Collaboration with community health workers and local immigrant-serving community-based and legal organizations was key to intervention design and implementation. Conclusion: Integrating legal education into medical care is one action health centers can take to support immigrant patients, address their complex realities, and optimize patients.


Introduction
Among the > 28 million patients who receive health care services from federally qualified health centers (FQHCs) 1 regardless of their ability to pay are immigrant patients who face unique barriers to care. Undocumented immigrants are a subset of this population who are particularly vulnerable. They disproportion-ately work in hazardous low-paying jobs that do not offer employment-based health insurance and remain ineligible for health insurance despite expansions made under the Affordable Care Act. [2][3][4][5][6][7][8][9][10] Undocumented immigrants also face sociopolitical stressors such as immigration enforcement, restrictive immigration policies, and anti-immigrant rhetoric at the federal, 4 state, [5][6][7][8][9] or local levels [10][11][12] that further contribute to negative health outcomes. Fear of discovery and deportation dissuades use of needed health services, 3 alongside being associated with poor mental health, worsening cardiovascular risk factors, lower self-reported general health, low birth weights among immigrant mothers, and reduced use of needed health care services. [13][14][15] The health impacts of these sociopolitical stressors transcend legal status, impacting immigrants with authorization, U.S. citizens in mixed immigration-status households, and those belonging to the same ethnic/minority communities due to perceived illegality. 7,8,11,13 To address immigrant patients' social needs, health systems have adopted ''immigration-informed'' interventions, including medical-legal partnerships that embed legal services into health care settings. [16][17][18][19] Legally oriented interventions have most commonly focused on providing patients with one-on-one legal advice or assistance through legal personnel. 16,17 These efforts expanded in the aftermath of the 2016 U.S. presidential election due to an increasingly anti-immigrant policy climate and heightened patient anxiety. 16,18,[20][21][22] Consequently, health systems implemented new interventions to support their immigrant patients, among them the integration of legal rights education within clinical care. 21 Yet this has not been described in the medical or public health literature. This observational qualitative case study describes the implementation of ''Know Your Rights'' (KYR) legal rights education in clinic waiting rooms of Clínica Monseñor Oscar A. Romero (Clínica Romero), an FQHC in Los Angeles, California.

Methods
We conducted key informant interviews, direct field observations, and document review from May to July 2018 using a descriptive qualitative case study approach. Clínica Romero was identified as part of a larger study assessing health care interventions aimed at mitigating immigration-related stressors for patients and providers. 21 Key informants were staff members of Clínica Romero's Community Outreach and Patient Services Department (COPSD; n = 4) who led implementation efforts for this intervention. Four field visits were conducted to observe KYR presentations (n = 2) and UndocuHealth Youth Program training sessions for the KYR presentations (n = 2). The UndocuHealth Youth Program was started in 2017 to foster commu-nity engagement and leadership skills development among local undocumented high school students while providing them a paid work opportunity.
Semistructured interviews ( Fig. 1) with four key informants were conducted. Observations, field notes, and interview notes were taken on site and typed within 24 h, including reflective journaling. Authors A.S. and A.F.-V. conducted descriptive and content analyses iteratively and through consensus. This study was approved by the University of California, Los Angeles Institutional Review Board.
Case study setting Clínica Romero's two clinic locations serve 12,000 predominantly low-income foreign-born Latinos. 23 Selfpaying and uninsured patients comprise 43% of the patient population. 23 The FQHC has 13 clinical providers, 2 behavioral health providers, 5 dentists, and 2 pharmacists. 24 The FQHC's COPSD, Community Health Workers (CHWs, or Promotores de Salud in Spanish), and local immigrant-serving communitybased organizations (CBO's) collaborate to improve civic engagement, capacity building, cultivation of resident leaders, and ensure enrollment in health programs.

Designing and integrating the ''Know Your Rights'' intervention
To address patients' immigration-related concerns, the COPSD collaborated with CHWs and local immigrantserving CBOs to design and implement a KYR legal education intervention (Table 1). Key informants described being motivated to address immigrationrelated concerns ''to dismantle the social determinants of health'' and to facilitate patient trust (''if [patients] don't trust [us], they're not going to come'') (see Table 2 for interview and field observation themes).
KYR presentations include discussion of legal rights, response to potential interactions with law enforcement, and identification of valid warrants ( Table 1). The director of the COPSD used a ''train the trainers'' model 25 to train COPSD staff as presentation facilitators. This training was supplemented by webinars, presentations, and conferences given by immigrantserving organizations such as the National Immigration Law Center and Asian Americans Advancing Justice. COPSD staff subsequently trained other presentation facilitators: CHWs and UndocuHealth Youth Program participants. 1. Tell me about the history of how you/your institution became involved in implementing these interventions?
2. What are the range of policies you have implemented at your institution? What have you considered implementing?
x Hospital/administrative interventions x Provider-focused interventions x Patient-focused interventions inside and outside hospital setting x Policies promoting the use of health care services x Policies outlining boundaries of interactions with immigration enforcement personnel 3. Can you tell me about how these policy interventions were decided on and implemented?
x Leadership?
x Community or legal consultation?
x Patient involvement?
x Resources?
4. What was difficult about the process? What challenges or resistance did you face? What did you have to overcome? What could you not overcome?
x Ask for each intervention 5. What would you do differently?
6. What would you recommend to other people?
7. Tell me about the plans for evaluation of these interventions? How will you measure "success"?  In January 2017, Clínica Romero began providing 5-to-10-min daily KYR presentations in the waiting room. Information provided during the session was similar to KYR advice offered by community-based and legal organizations. Sessions were introduced in a neutral tone and information was framed as relevant to everyone, regardless of immigration status. Facilita-tors emphasized applicability of content to any law enforcement interactions, including Immigration and Customs Enforcement.
Facilitators used materials (Fig. 2) such as visual aids during presentations that were provided for patients to refer to and take home. These supplemental materials include a sample warrant ( Fig. 2A), KYR brochure ''Our patients and our communities always deserve consistency and commitment. and building trust comes with a lot of commitment and a lot of consistency.'' ''It has to deal a lot with trust at the end of the day, because if they don't trust [us], they're not going to come.'' Patient and community empowerment ''We have to think for and by our patients, right? So we did a small assessment as to what the immediate needs were. And one of them was they didn't know their rights. so the things that we did were empower. We have developed groups of patients and community at large to not only know their rights, but also go and say their rights and teach others so it becomes a ripple effect.'' ''Empowering a person is giving them tools. It's the same way we teach cancer education. We're not going to say, 'By the way you have 1 in 4 chances of getting cancer and you might die.' No. We give them the problem, we give them the solution, and then give them the tools.'' Developing and strengthening clinic-legal partnerships ''We developed a public, private partnership that could assist the population that we were serving or that we are serving.'' ''We wanted to make sure that they had every tool needed for our efforts to be successful. We developed a list of private public partnerships. We had conversations with them. It was a lot of leg work, but it was well worth it. When we would go out and finally do any sort of trainings in our community, it was done correctly. We wanted to make sure that it was done with a lot of forethought in mind.'' Themes from field observations (n = 4)

Theme Narrative description
Fostering patient trust throughout presentation KYR presentation information was offered in a nonjudgmental manner with offer for navigation support throughout the presentation (e.g., calling lawyer contact information, additional review of KYR cards or valid warrant examples). KYR presentations were viewed as a method to connect with patients and strengthen trust in the clinic. Each interaction viewed as an opportunity to build trust. Patients were invited to ask questions both in group setting during the presentation and in one-on-one after presentation was completed accommodating for different patient preference. Informal but communityengaged evaluation process Presenters kept a general list of questions patients asked and tried to incorporate them into subsequent presentations so there was an iterative process in improving these presentations No formal evaluation of patient-level response or satisfaction but promotores were in constant contact with patients and community members and brought feedback to COPSD team during weekly meetings UndocuHealth youth program participants, who were members of the community, provided feedback on length and content of presentations Observed patient responses to KYR presentations Many initially appeared indifferent but became more engaged when certain topics were discussed and resources or examples provided (e.g., lawyer contact information, KYR cards, valid warrant examples) Most approached facilitator with individual questions after presentation concluded rather than asking questions in the group Some only took the material or asked for materials and walked out of the waiting room without listening to the entire presentation. Audience appeared more attentive when presentations were provided by staff rather than the youth Patients expressed concern and fear of sharing personal information on sign-up sheets and referrals due to concerns of immigration status discovery Observed barriers to effective presentations containing a summary of presentation content (Fig. 2B), KYR card (Fig. 3), and a local legal resource guide. Clínica Romero developed partnerships with legal organizations listed on their resource guide to provide patients a free initial consultation at these organizations. The facilitators offered community resource navigation support.
Waiting room KYR presentations were conducted in Spanish because > 90% of the clinic's patients are Spanish-speaking only. Table 3 provides the number of patients seen from 2017 to 2020 (with a range of 2-10 patients in a waiting room at any given time). Facilitators encouraged questions throughout, and stayed in or around the waiting room for an additional Sus Derechos x Usted tiene el derecho de permanecer en silencio. Si desea ejercer ese derecho, dígalo en voz alta.
x Usted tiene el derecho de negar permiso a un registro de su persona, vehículo, o casa. x Si no esta bajo arresto, tiene el derecho de irse con calma. x Usted tiene el derecho a un abogado, si lo arrestan. Pida una inmediatamente.
Sus Responsabilidades x Guarde la calma y sea amable.
La tarjeta explica que usted quiere ejercer su derecho a no contestar preguntas sin consultar con un abogado.

Know Your Rights!
If you are detained by immigration or the police: Hand the card off to the official and remain silent.
The card explains that you are executing your right to refuse to answer any questions until you have consulted with a lawyer.

To Whom It May Concern:
Please be informed that I am choosing to execute my right to remain silent and the right to refuse to answer your questions. If I am detained, I request to contact an attorney immediately. I am also executing my right to refuse to sign anything until I consult with my attorney.
Thank you.

FIG. 3. Printable bilingual Know Your Rights cards.
5-10 min after the formal presentation ended to address individual questions, share additional resources, and offer help with connecting to a lawyer if needed.

Program sustainability and evaluation
To ensure sustainability, the execution of the KYR presentations was integrated into the UndocuHealth Youth Program and the COPSD staff position responsibilities. CHWs also incorporated these presentations into their health education programming around conditions such as diabetes, hypertension, and mental health, in schools, churches, and other community venues. Weekly meetings with the CHW team ensured that feedback was exchanged between both teams to adapt these presentations as needed. Given staffing and funding limitations, formal evaluation of this intervention has yet to be conducted but is forthcoming.

Program challenges
The waiting room setting posed various challenges for effective presentations, although providing a captivated audience. First, the noisiness of the waiting room sometimes distracted patients or overcame the facilitator's voice. To overcome this challenge, the team piloted conducting one-on-one presentations with patients within the waiting room. Another potential approach is turning off or lowering the volume of the waiting room television while presentations are occurring to minimize distractions. Second, the clinic noted variation in patient attendance with changing immigration policies, including ongoing public charge discussions 22 ; this made concurrent presentations in other community spaces such as schools and churches vital to reaching and empowering the most patients possible rather than relying on clinic waiting rooms alone. Community events were conducted in English and Spanish to address language needs of attendees. Third, there was a tension between clinic goals: on one hand, decreasing waiting room times, and on the other, ensuring adequate time to provide legal information and resources. Having front desk staff provide patients with KYR materials at check-out could increase dissemination of information regardless of patient wait time. Fourth, there remain challenges with funding for this intervention and incorporating needs of different immigrant populations as African and Asian immigrants become members of the clinic population. The COVID-19 pandemic has posed the ultimate challenge such as staff presence, in-person interactions, and waiting room time are minimized. The FQHC paused waiting room KYR presentations initially but later integrated them within COVID-19 response efforts (i.e., CHWs offering one-on-one KYR legal education to individuals receiving their COVID-19 testing or vaccinations).

Future directions
Future study should assess patient perspectives of these interventions to most effectively address their concerns and promote trust in health care systems. This is particularly urgent during the COVID-19 pandemic when vaccination of all communities, particularly disproportionately affected immigrant communities, is needed for effective public health. Furthermore, FQHCs are particularly suited for these efforts given their position as a primary source of medical care for uninsured immigrants, trusted relationships, locations in the community, and enabling services such as language access; next steps could identify generalizability of this intervention to other health care facility types.

Conclusion
FQHCs are uniquely positioned to serve as places of innovation to address the needs of communities they serve. 26 This case study describes an innovative integration of KYR legal rights presentations into the clinical care of immigrant patients, developed in partnership with local community and legal organizations. It reflects a national trend of health care facilities addressing patient legal needs to improve health outcomes. 18 In the setting of the COVID-19 pandemic, integrating provision of patient legal rights education into pandemic response efforts represents a critical strategy in addressing fears that may hinder testing or vaccination efforts. This case study underscores that there are many creative ways immigration-related fears can be addressed in the health care context to optimize equitable patient care for immigrants and their families.

Author Disclosure Statement
No competing financial interests exist.

Funding Information
Ms. Lemus acknowledges funding support for the waiting room Know Your Rights workshops from the California Department of Social Services.