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Introduction Newly arrived immigrants to the USA who have time-sensitive medical or mental health needs face a fragmented and often insufficient system of support. This qualitative study explored the perspectives of individuals and organisations who support immigrants across their immigration journey and sought ideas to better identify and connect people in need with care.Methods From June to August 2024, semistructured consultative sessions were conducted with individuals working with recently arrived immigrant families across both sides of the US Southern border, as they transition to and arrive at their US destination. Reflexive thematic analysis was used by researchers with relevant lived experience to interpret the data and develop the analytic themes.Results A total of 58 individuals representing 35 organisations from 14 US states and Mexico participated in the study. Participants came from a wide range of sectors including academic institutions, border respite centres, community-based organisations on both sides of the US-Mexico border, local government and Customs and Border Protection officials, health navigators, nurse midwives and physicians. Qualitative analysis of interviews revealed key themes including gaps in identification and access to care for medically at-risk immigrants at the border and throughout the USA, extensive violence and trauma that many experience and subsequent need for acute and long-term mental health support, unique social, linguistic and structural barriers faced by this population and finally the need for innovative solutions and health-centric policies to address these complex issues.Conclusions Although the immigration landscape is constantly changing, certain fundamental medical and health-related social needs remain constant. Innovative solutions are required to improve the health and well-being of immigrants. This can only be achieved by elevating the expertise of the people and organisations who engage directly with immigrants on their journey.