Background: Although nearly every participating provider group in Medicare’s Oncology Care Model sought to reduce emergency department (ED) use by their patients with cancer, few achieved this. Despite growing spread of specialized oncology urgent care clinics (OUCC) as an ED-alternative to treat commonly anticipated treatment-related symptoms, these clinics are underused. The University of Texas Southwestern (UTSW) and Dallas County Safety-net (Parkland Health) have run OUCCs since 2015. Parkland patients use the ED twice as often as UTSW patients in the first 6 months after cancer diagnosis. Utilizing semi-structured interviews, we investigated oncology patient perspectives on acute care needs and ED decision-making in both systems among English and Spanish-preferring patients. Methods: We interviewed 24 UTSW and 16 Parkland oncology patients (5 English-preferring, 11 Spanish-preferring). UTSW is an urban regional academic referral center serving nearly 8 million people with a cancer patient population that is 35% nonwhite and 7% Medicaid or uninsured. Parkland serves patients in Dallas County including a cancer patient population that is 77% nonwhite and 80% with Medicaid or county charity care (uninsured). Translated transcripts were analyzed using iterative thematic analysis and the constant comparative method. We evaluated decision-making, attitudes, beliefs, and barriers to access that influenced decisions to present to the ED across a diverse patient population. Results: Patients in both health systems endorsed that they did not receive adequate information about expected side effects from cancer treatment. UTSW patients described direct access (e.g., personal cell phone numbers) to their oncologist, whereas Parkland patients commonly relied on non-clinician family to triage symptoms. Parkland patients reported experiencing barriers to outpatient care (lack of insurance, language barriers, and limited access to outpatient care), and described an acculturation to visiting the ED for acute care needs. When patients called a clinician for triage advice, they were often referred to the ED. Overall, patients were largely unaware of OUCCs and a 24/7 telephone triage line, but were very interested in accessing the OUCC to avoid prolonged wait times and exposure to infectious pathogens in the ED. Conclusions: Among ED-visiting patients with cancer, we found notable disparities in rapid informal access to clinicians between oncology patients receiving care through UTSW compared to Parkland. Highlighting the available 24/7 phone line as part of patient counseling on treatment side-effects might mitigate this disparity in access, increase utilization of the OUCCs, and reduce low-acuity ED visits in both health systems. Patient perspectives provide valuable insights on how to better integrate care delivery innovations for this high-risk population.