WestBay Alliance &

Brimbank Melton PCP

Care Planning for Refugee Health

An Evolving Model

Care Planning and Refugee Health

• Refugee health care is complex and involved.

• Its success is dependant upon an integral understanding of the ‘whole’ picture of what is going on in a refugee’s life.

• Refugee Care Planning must be done within the framework of the service coordination pathway.

• It must involve consideration of the other issues going on for the refugee.

Background to Primary Care Partnership (PCP)

Refugee Health Projects

• One-off statewide initiative to support the integration of newly arrived refugee entrants.

• Facilitated by Primary Health Branch of the Department of Human Services (DHS).

• Funds allocated to each of the 8 PCPs where Refugee Health Nurses (RHNs) are situated.

• Projects complimented the RHN Initiative.

Aim of the Refugee Projects• To develop stronger, more integrated, and

community-based, health and community services for refugees by:

– Reducing duplicative practices.– Increasing understanding of referral and

care pathways.– Improving service coordination and

care planning.– Delivering integrated health

promotion practice.

This PCP Project

• A joint Refugee Health Project for the

2 Primary Care Partnerships (PCPs):

• WestBay Alliance (PCP)

– Wyndham

– Hobsons Bay

– Maribyrnong

• Brimbank / Melton PCP

Project Objectives

• To progress work on developing care pathways for refugees across a range of service providers.

• In partnership and cooperation with GP Divisions:– Improve care coordination between GP

practices and health providers. – Support new GPs willing to work with

refugees.

Objectives cont.

• To identify and link with other appropriate services such as Infectious Disease Units.

• To encourage the use of the Service Coordination Tool Template and the Statewide GP Referral Template.

• Identify and prioritise service gaps and workforce development needs.

• To identify opportunities for further funding / support.

Steps involved in the Project

1. Established an advisory group with 2 key service providers – WRHC & ISIS

2. Held discussions with Refugee Service Providers in the 5 LGAs.

3. Mapped Current Care Pathway.

4. Documented Enablers and Barriers to Refugee’s access to and experiences with the health system.

Discussions with Service Providers

• Western Region Health Centre • AMES – Adult Multicultural Eduction Services • Migrant Resource Centre • GP Divisions – Western Melbourne and Westgate• Royal Melbourne Hospital • ISIS Deer Park • Royal Children’s Hospital - Immigrant Clinic • Victorian Foundation for Survivors

of Torture• Western Hospital

Discussions with Service Providers cont.

• Maribyrnong City Council• Brimbank City Council• Maribyrnong & Brimbank Family Services• Other Metropolitan PCPs• Melbourne City Mission • Royal Women’s Hospital• Dinka & Karen Refugee Representatives• New Hope Foundation• Local Churches

Mapping Current Care Pathway according to Service

Coordination Principles• The documentation of current care

pathways occurred after discussions with many settlement and health service providers.

• These pathways attempt to map how a refugee negotiates the settlement and health system, after they arrive in the country.

INITIAL CONTACT

INITIAL NEEDS IDENTIFICATION

INITIAL ASSESSMENT

CARE PLANNINGSETTLEMENT

SUPPORTPRE-DEPARTURE

MEDICAL SCREEN(PDMS)

200 & 204Refugee Entrant

PDMS arranged within 72 hrs prior

to travel

AMES Case Worker arranges medical

attention for alert cases and later health

assessment

Entrant provided PDMS papers

(including Red or Yellow Alert or signed Health Undertaking)

DIAC informs AMES of entrant's arrival

AMES informs consortium agencies -

Red Back, Brotherhood of St Laurence, VFST

VISATYPE

AMES provides Case Worker within 24 hours

& Community Guide Support for 6 months

CURRENT CARE PATHWAY

FOR REFUGEE ACCESS TO HEALTH SERVICES IN

Maribyrnong, Hobson's Bay & Wyndham, Brimbank & Melton

Western Hospital Migrant Screening (TB Clinic) send

appointment letter to entrant

Refugee Health

Nurse (RHN) where present

Public Laboratory Testing Centres

(Radiology, Pathology,

Immunology)

RCH Immigrant

Screening Clinic

RMH Infectious Diseases

Clinic

Refugee Health Nurse

screens entrants for health

assessments

Private Laboratory Testing Centres

(Radiology, Pathology,

Immunology)

FURTHERASSESSMENT

Public or Private

Bulk-billingGP Clinics

(with refugee interest)

RMH Infectious Diseases Clinic

RCH Immigrant Screening Clinic

TREATMENT &FOLLOW-UP

VFST(Psychological Counselling)

Medicare funded Psychologist

Pharmacy

Dietician

Optometrist

Maternal & Child Health

Within Hospitalor Health Centre

Radiology, Pathology, Pharmacy, Immunology,

Counselling etc.

Allied Health (Physio, OT, Podiatry etc)

Dentist

Royal Women's Hospital

DIAC inform Western Hospital (WH) Migrant Screening (TB Clinic) of health undertaking

entrants

AMES Case Worker (if aware of WH

appointment) ensures entrant attends

Public or PrivateBulk-Billing GP Clinics

with RefugeeInterest (Yellow Alert or Health Assessment)

VFST for Psych screening

assessment

WH Radiology

WH Migrant Screening Clinic

DoctorsWH Infectious

Diseases Clinic

202Special

Humanitarian Entrant (SHP)

PDMS difficult to arrange but Visa

Medical Examination conducted

AMES Case Worker informs proposer how

to access health assessments

AMES arranges Brotherhood of

St. Laurence for furniture package

DIAC provides AMES with

proposer's details

AMES provide case worker, who contacts

proposer with checklist of orientation information

DIAC inform Western Hospital (WH) Migrant Screening (TB Clinic) of health undertaking

entrants

CURRENT SETTLEMENT PATHWAY

REFUGEE & SPECIAL HUMANITARIAN PROGRAM

VISA HOLDERS IN

Maribyrnong, Hobson's Bay & Wyndham, Brimbank & Melton

GAP

Some refugees (202s) get lost at this stage

VUT, WELS & other schools,

Churches & Charities pick up

these refugees over time

(up to 3 years)

ASSESSMENT

Public or Private

Bulk-billing GP Clinics

(with refugee interest)

Hospital Emergency Department (Red Alert)

Community Health

Nurse (CHN) where no RHN

present

WH Infectious Disease Clinic

WH TB Clinic

WH Hepatitis Clinic

WH Migrant Screening Clinic

Doctors

WH Migrant Screening Clinic Doctors

Public or Private

Bulk-billing GP Clinics

(with refugee interest)

WH Hepatitis Clinic

WH Infectious Disease Clinic

WH TB Clinic

WH Hepatitis Clinic

RMH Infectious Diseases Clinic

Maternal & Child Health

Royal Women's Hospital

Dentist

Dietician

Optometrist

Allied Health (Physio, OT, Podiatry etc)

Community Support Groups

Medicare funded Psychologist

VFST(Psychological Counselling)

RCH TB Clinic

STD Clinic Melbourne

STD Clinic Melbourne

DRAFT DRAFT DRAFT DRAFT DRAFTWestBay Alliance and Brimbank Melton PCPs

Refugee Health Service Coordination Project

DRAFT DRAFT DRAFT DRAFT DRAFTWestBay Alliance and Brimbank Melton PCPs

Refugee Health Service Coordination Project

Current Care Pathway

Barriers experienced by Refugees during Pathway Negotiation

• The complexities and duplication in the process. • Misunderstanding about Pre-Departure Medical

Screen results. • Different allocations of support for different Visa

holders.• Health system illiteracy and ignorance about

health system negotiation • ‘Falling through the cracks’ before establishing

a connection with health system.

Barriers experienced by Refugee cont.• Initial TB screening only conducted at Western

Hospital for the whole state.

• Gaining access to an Interpreter when unable to speak or understand English.

• Waiting lists for appointments and services.

• High health demands due to years spent in refugee camps with poor diet, limited resources, and limited access to essential medical care.

• Public transport access and a different concept of time-keeping for appointments.

• Confusion and misunderstanding about tests / medication / therapy / follow-up.

Steps involved in the Project cont.5. Developed a Proposed Care Pathway, with

incorporated enablers.

6. Developed a Complexity Screen

7. Presented results to service providers at a forum (up to 50 providers).

8. Established a working group of selected service providers (18 members) to refine pathway and complexity screen.

9. Developed a protocol to guide implementation.

10. Provided feedback to larger group at a second forum.

Developed a newProposed Care Pathway

• Based on Service Coordination principles.• More efficient and unified.• Facilitating health access that is more:

– streamlined– structured– supportive of the newly arrived refugee.

• Uses ‘intake’ and ‘access’ roles or personnel to assist the refugee along the Care Pathway suited to the complexity of their situation

INITIAL CONTACTINITIAL NEEDS

IDENTIFICATIONINITIAL

ASSESSMENT

CARE PLANNING

SETTLEMENTSUPPORT

PRE-DEPARTURE MEDICAL SCREEN

(PDMS)

200 & 204Refugee Entrant

Brotherhood of St. Laurence

Furniture package

PDMS occurs within72 hrs. Can include

pre-departure results form,

health manifest & health undertaking

VISATYPE

Case Coordinator & Community Guide

for 200 & 204 entrants

(for 6 months) & on request

for 202

PROPOSED HEALTH CARE PATHWAY

FOR REFUGEE ACCESS TO HEALTH SERVICES IN

Maribyrnong, Hobson's Bay & Wyndham, Brimbank & Melton

Health Underrtaking -WH Migrant Screening (Statewide TB Clinic

for Health Undertaking)

Refugee Health

Nurse (RHN) (where

present)

RCH ImmigrantScreening Clinic

RMH Infectious Diseases Clinic

Combined initial

assess-ment with Refugee, RHN or CHN &

Interpreter

Active TB

FURTHER ASSESSMENT

TREATMENT &FOLLOW-UP

Community Support Groups

Allied Health (Dentist,

Optometrist, Dietician,

Audiologist, PT/OT etc)

Foundation House

- Intensive Psych

assessment

No TB

Latent TB

Western HospitalTB Clinic

202Special

Humanitarian (SHP) Entrant

Also Visas 201, 203, 866 are eligible for

some services

PDMS rare but Visa Medical Examination conducted (including health undertaking)

ASSESSMENT

Foundation House

(Psychological Counselling)

PROPOSED SETTLEMENT PATHWAY

REFUGEE & SPECIAL HUMANITARIAN PROGRAM VISA HOLDERS IN

Maribyrnong, Hobson's Bay & Wyndham, Brimbank & Melton

Community Health Nurse

(CHN) (where no

RHN available)

Foundation House- Psych screening

assessment

AMES Community

Guide / Access Worker / Volunteer Support arranges appoint-ments &

transport-ation

Hospital Specialist or Public /

Private GP with RHN / CHN coordinates

further assessments

DIAC INITIAL CONTACT

DIACinforms

AMES of entrant

arrivals or proposer

details

AMES Settle-ment

Support

Red BackAirport transport & temporary housing

Specialist Women's

Health

Specialist Medical

Specialist Mental Health

447, 451, 695, 785, 786 & 070

Visas

ClinicNurse @ GP Clinic

or GP

Initial assessment

with Refugee & Interpreter

AMES Community

Guide / Access Worker / Volunteer Support arranges appoint-ments &

transport-ation

Public /Private GP with RHN /

CHN and liaison with AMES

Case Coordinator decide onCare Plan

andTreatment

Specialist Medical

Allied Health (Dentist,

Optometrist, Dietician,

Audiologist, PT/OT etc)

Specialist Women's

Health

Specialist Mental Health

Attempts to apply for Refugee StatusAll health and social needs met by voluntary medical, legal and social assistance, who provide assessment, care planning and treatment through donated resources,

at Asylum Seeker Resource Centre or equivalent

RCH TB Clinic

WH Hepatitis Clinic

WH Infectious Diseases Clinic

Red Alert -Hospital

Emergency Dept

Yellow Alert -Public or Private

Bulk Billing GP Clinic with

Refugee Interest

AMES Community

Guide / Access Worker / Volunteer Support arranges appoint-ments &

transport-ation

Public or Private Bulk

Billing GP Clinic

with Refugee Interest

Public Laboratory Testing Centres (Radiology,

Pathology, Immunology)

Private Laboratory Testing Centres (Radiology,

Pathology, Immunology)

Within Hospital or Health Centre

Radiology, Pathology, Pharmacy,

Immunology, Counselling etc.

TOOLS

* Pre-Departure Medical Screen (PDMS)

AMES * Holistic

Assessment &* Complexity

Tool

High Complexity 200 & 204 Cases and 202 Cases

(on request)

Low Complexity 200 & 204 Cases and 202 Cases

(on request)

* Refugee Health Assessment &

SCTT * Consumer Consent to

share information* Confidential Referral

Cover Sheet* Consumer Information* Summary & Referral

MBS * Refugee

Health Assessment

&SCTT

* GP Referral Template

SCTT* GP Referral

Template

SCTT* GPMP* TCA

* Organisational Profiles

* Functional Assessment Summary

SCTT* Service

Coordination Plan

Proposed Roles & Responsibilities of Service Providers in Health Care Pathway (new responsibilities are in blue)

Department for Immigration and Citizenship (DIAC) * Ensures (where possible) that IOM (International Organisation for Migration) has carried out and forwarded PDMS (Pre-Departure Medical Screen) results* Refers to AMES (Adult Multicultural Education Services) all Refugee and SHP (Special Humanitarian Program) entrants who have been provided with Visas. * Includes PDMS information in referral to AMES* Informs AMES of Health Undertaking referrals to WH (Western Hospital) Migrant Screening Clinic

AMES Case Coordinator * Coordinates referrals to consortium partners* Conducts holistic screen of entrant's needs* Conducts Complexity Assessment to determine health referral pathway* For high complexity cases: Coordinates referral to RHN / CHN and follows-up RHN / CHN meeting with entrant and interpreter to complete initial health needs identification summary and referral to GP* For low complexity cases: Coordinates referral to GP with Clinic Nurse, providing appropriate entrant information. Clinic Nurse arranges initial assessemnt with interpreter and entrant and/or GP. * Coordiates appropriate and corresponding Community Guide / Access Worker / Volunteer support* Communicates with GP and RHN / CHN for input into Team Care Plan (Service Coordination Plan)* Empowers and educates entrant in involvement and management of their own health care plan

Refugee Health Nurse (RHN) / Community Health Nurse (CHN) / Clinic Nurse * Conducts initial health needs identification with refugee and interpreter, and communicates with AMES Case Coordinator regarding action and referrals* Ensures appropriate referral and entrant information is forwarded to GP (ideally as part of Refugee Health Assessment or Service Coordination Tool Templates - SCTT)* Liaises with AMES Case Coordinator and GP regarding entrant's health needs* Meets with GP and consults with AMES Case Coordinator about Team Care Plan (Service Coordination Plan)

General Practitioner (GP)* Receives health information from RHN/CHN, Clinic Nurse or AMES Case Coordinator* Conducts MBS Refugee Health Assessment* Refers to appropriate tertiary or diagnostic centres (minimising the number of appointments for the entrant where possible)* Liaises with RHN / CHN and AMES Case Coordinator in regard to results, follow-up treatment and care planning

Tertiary Hospital Clinics* Conduct appropriate tests and screening for specific disease conditions* Liaise closely with GP in regard to results and follow-up treatment* Implements Care Pathway principles

Specialist and Allied Health* Conduct specialised assessments as requested* Liaise with GP in regard to follow-up t reatment and care planning* Implements Care Pathway Principles

Principles underlying success of Health Care Pathway Implemen-tation

* Client Focussed & Empowering

* Informed Consent & Privacy

* Culturally Sensitive & Respectful

* Information Provision & Sharing

* Partnership Including Refugee

* Collaboration Between Agencies & Client

* Shared Responsibility

* Strengths Based

* Proactive Approach

* Reduced Duplication

* Effective Communication & Feedback

* Appropriate Training & Education

DRAFT DRAFT DRAFT DRAFT DRAFT

DRAFT DRAFT DRAFT DRAFT DRAFTWestBay Alliance and Brimbank Melton PCPs

Refugee Health Service Coordination Project

WestBay Alliance and Brimbank Melton PCPsRefugee Health

Service Coordination Project

AMES Community

Guide / Access Worker

etc arranges transport-

ation

010 Asylum Seeker(Bridging Visa

A or E)

Hospital Emergency Department

Community Health Centre

Proposed Care Pathway

Enablers of Proposed Care Pathway

• An ‘ideal’ pathway – something to aim for? • May not be achievable immediately, but some

aspects can be put in place now.• Has the goal of improved service

coordination and care planning.• Based on the Social Model of Health.• Outlines the roles and responsibilities of those

involved in the Care Pathway.• Outlines the Principles underlying the

implementation of the Care Pathway.

Enablers of Proposed Care Pathway cont.• Indicates different pathways, depending on the

complexity of the refugee.• Allows for additional support to be provided

(eg. by community guides, access workers or volunteers) for refugees and their families, who have more complex needs.

• Accounts for all visa holders and their various entitlements.

• Indicates the relevant assessment, communication and care planning tools to be used (SCTT and others).

Enablers of Proposed Care Pathway cont.• Attempts to reduce number of appointments for

refugees.• Utilises the MBS item number for GPs who do a

comprehensive Refugee Health Assessment.• Involves referral to specialist services for

specific assessment and ongoing treatment.• Incorporates regular, informative discussion

between GP, Nurse & AMES Case Coordinator, to ensure effective case management and care planning.

Developed a Complexity Screen

• To measure the level of complexity and urgency in a refugee situation.

• To ensure appropriate levels of support are provided for refugees to enable access and efficiency of further assessment.

• To encourage communication between service providers regarding the specific needs of each refugee.

Contents of Complexity Screen• Purpose of Tool / Screen• General Information• ‘Alert’ Health Information• Education Level• Pre-Arrival Experience• Family Composition• Living Situation• Health Situation• Complexity and Urgency Score and Action• Professional Judgement

So how does all this relate to Care Planning?

• Refugee Care Planning could not be done well, if this process had not occurred.

• The steps in this project have established a solid foundation for care planning.

• Key Principles:– Interagency collaboration and useful

discussion– Willingness to change if it makes access

easier for the client– Keeping the client and their circumstances at

the centre of the planning

Essential ingredients for good Care Planning

Outlined in the Principles underlying thesuccess of the Refugee Care Pathway:

• Client focused and empowering• Informed consent and privacy• Culturally sensitive and respectful• Information provision and sharing• Partnership – including refugee• Collaboration between agencies

and client

Essential ingredients for good Care Planning cont.

• Shared responsibility

• Strengths based

• Proactive approach

• Reduced duplication

• Effective communication and feedback

• Appropriate training and education

Thank You!

Questions?

WestBay Alliance &

Brimbank Melton PCP