Operationalizing California hospital responses to immigration enforcement: a two-site implementation report

Background Healthcare institutions must navigate the operational intersection of federal immigration enforcement and state-level privacy mandates, while prioritizing patient care. California’s Senate Bill 81 (SB 81; ‘Health and Care Facilities: Information Sharing,’ 2025) provides a legal framework governing immigration enforcement access to healthcare facilities and patient information. SB 81 expands protected health information to include patients’ place of birth and immigration status, requires hospitals to establish clear internal policies for immigration enforcement interactions, and restricts access to nonpublic areas in healthcare facilities. However, health systems lack protocols for frontline staff. This implementation gap is a pressing concern as multiple states consider similar legislation, creating a national need for standardized operational models. This paper examines the implementation of SB 81 and key operational variables at two distinct California clinical environments to guide institutional responses to immigration enforcement encounters in alignment with SB 81. The resulting framework offers an adaptable model for health systems nationwide to respond to state laws while maintaining patient safety and clinical quality outcomes. Methods Both institutions’ operationalization began with emergency department (ED) physician-initiated workgroups. At the large academic hospital, the workgroup included physicians, nursing leadership, executive operations, legal counsel, compliance, and internal law enforcement. New hospital policies were established. Public and nonpublic areas were defined based on function rather than physical layout. At the large county hospital, the workgroup included physicians, executive operations, organizational risk management, and city legal counsel, which also served as counsel for the sheriff’s department. Pre-existing hospital policies regarding interactions with law enforcement were used to reinforce guidance for interactions with immigration enforcement officers. Results Across both institutions, the operational framework aligned with Prosci’s ADKAR model of change and was structured around four core domains: hospital zoning, centralized authority, standardized response protocols, and care of patients in custody. Outcome data is pending. Key insights thusfar include the importance of proactive interprofessional alignment, visible designation of public versus nonpublic areas, and early engagement with law enforcement partners. Establishing shared expectations before encounters may reduce bedside escalation risk and clarify legal boundaries. Discussion Although SB 81 implementation varies, the underlying operational pillars remain consistent: clear hospital zoning, centralized authority, standardized response procedures, and protocols for patients in custody. This multidisciplinary framework provides a practical blueprint that health systems can adapt to their organizational needs and evolving state legal requirements while prioritizing institutional stability and clinical integrity. Further work is needed to determine reinforcement practices and outcome data for healthcare organizations adopting this framework.