Transcript Slide 1

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
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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.
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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.
Current Care Pathway
DRAFT
DRAFT
DRAFT
DRAFT
CURRENT SETTLEMENT
PATHWAY
CURRENT CARE PATHWAY
FOR REFUGEE ACCESS
TO HEALTH SERVICES IN
REFUGEE & SPECIAL HUMANITARIAN
PROGRAM
VISA HOLDERS IN
Maribyrnong, Hobson's Bay & Wyndham,
Brimbank & Melton
Maribyrnong, Hobson's Bay & Wyndham,
Brimbank & Melton
VISA
TYPE
200 & 204
Refugee
Entrant
SETTLEMENT
SUPPORT
PRE-DEPARTURE
MEDICAL
SCREEN
(PDMS)
INITIAL
CONTACT
ASSESSMENT
INITIAL NEEDS
IDENTIFICATION
INITIAL
ASSESSMENT
DIAC inform Western
Hospital (WH) Migrant
Screening (TB Clinic)
of health undertaking
entrants
CARE PLANNING
TREATMENT &
FOLLOW-UP
WH TB Clinic
WH TB Clinic
WH Migrant Screening
Clinic Doctors
RCH TB Clinic
WH Infectious
Disease Clinic
WH Infectious
Diseases
Clinic
STD Clinic
Melbourne
WH Hepatitis
Clinic
WH Hepatitis
Clinic
Pharmacy
RMH Infectious
Diseases Clinic
RMH Infectious
Diseases Clinic
Maternal &
Child Health
RCH Immigrant
Screening Clinic
STD Clinic
Melbourne
FURTHER
ASSESSMENT
WH Migrant
Screening Clinic
Doctors
Western Hospital
Migrant Screening
(TB Clinic) send
appointment letter
to entrant
PDMS arranged
within 72 hrs prior
to travel
WH Radiology
Within Hospital
or Health Centre
DIAC informs AMES of
entrant's arrival
WH Migrant
Screening Clinic
Doctors
AMES Case Worker
(if aware of WH
appointment) ensures
entrant attends
Entrant provided
PDMS papers
(including Red or
Yellow Alert or signed
Health Undertaking)
WestBay Alliance and Brimbank Melton PCPs
Refugee Health
Service Coordination Project
DRAFT
Radiology, Pathology,
Pharmacy, Immunology,
Counselling etc.
AMES informs
consortium agencies Red Back, Brotherhood
of St Laurence, VFST
WH Infectious
Disease Clinic
Hospital
Emergency
Department
(Red Alert)
AMES provides Case
Worker within 24 hours
& Community Guide
Support for 6 months
WH Hepatitis
Clinic
Public or
Private
Bulk-billing
GP Clinics
(with refugee
interest)
GAP
AMES Case Worker
arranges medical
attention for alert cases
and later health
assessment
Some
refugees
(202s)
get lost
at this
stage
DIAC inform Western
Hospital (WH) Migrant
Screening (TB Clinic)
of health undertaking
entrants
202
Special
Humanitarian
Entrant (SHP)
PDMS difficult to
arrange but Visa
Medical Examination
conducted
DIAC provides
AMES with
proposer's details
Public or Private
Bulk-Billing
GP Clinics
with Refugee
Interest (Yellow
Alert or Health
Assessment)
Refugee
Health
Nurse (RHN)
where present
RMH
Infectious
Diseases
Clinic
RCH
Immigrant
Screening Clinic
Refugee Health
Nurse
screens entrants
for health
assessments
Public or
Private
Bulk-billing
GP Clinics
(with refugee
interest)
Public Laboratory
Testing Centres
(Radiology,
Pathology,
Immunology)
AMES provide case
worker, who contacts
proposer with checklist of
orientation information
AMES arranges
Brotherhood of
St. Laurence for
furniture package
AMES Case Worker
informs proposer how
to access health
assessments
DRAFT
DRAFT
Royal Women's
Hospital
Dentist
Dentist
Dietician
Optometrist
Allied Health
(Physio, OT,
Podiatry etc)
VFST for Psych
screening
assessment
Community
Health
Nurse (CHN)
where no RHN
present
Maternal &
Child Health
Royal Women's
Hospital
Private Laboratory
Testing Centres
(Radiology,
Pathology,
Immunology)
Public or
Private
Bulk-billing
GP Clinics
(with refugee
interest)
Dietician
Optometrist
Allied Health
(Physio, OT,
Podiatry etc)
Community Support
Groups
Medicare funded
Psychologist
Medicare funded
Psychologist
VUT, WELS &
other schools,
Churches & Charities
pick up
these refugees
over time
(up to 3 years)
DRAFT
VFST
(Psychological
Counselling)
DRAFT
DRAFT
VFST
(Psychological
Counselling)
WestBay Alliance and Brimbank Melton PCPs
Refugee Health
Service Coordination Project
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 new
Proposed 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
Proposed Care Pathway
DRAFT
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
DRAFT
DRAFT
DRAFT
PROPOSED HEALTH CARE PATHWAY
PROPOSED SETTLEMENT PATHWAY
FOR REFUGEE ACCESS
TO HEALTH SERVICES IN
REFUGEE & SPECIAL HUMANITARIAN
PROGRAM VISA HOLDERS IN
Maribyrnong, Hobson's Bay & Wyndham, Brimbank & Melton
Maribyrnong, Hobson's Bay & Wyndham, Brimbank & Melton
SETTLEMENT
SUPPORT
DIAC INITIAL CONTACT
WestBay Alliance and Brimbank Melton PCPs
Refugee Health
Service Coordination Project
DRAFT
ASSESSMENT
INITIAL NEEDS
IDENTIFICATION
INITIAL CONTACT
INITIAL
ASSESSMENT
VISA
TYPE
PRE-DEPARTURE
MEDICAL SCREEN
(PDMS)
Active TB
Health Underrtaking WH Migrant Screening
(Statewide TB Clinic
for Health Undertaking)
Red Alert Hospital
Emergency
Dept
Red Back
Airport transport &
temporary housing
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
200 & 204
Refugee Entrant
Brotherhood of
St. Laurence
Furniture
package
PDMS occurs within
72 hrs. Can include
pre-departure
results form,
health manifest &
health undertaking
DIAC
informs
AMES of
entrant
arrivals or
proposer
details
AMES
Settlement
Support
AMES
Community
Guide /
Access Worker
etc arranges
transportation
Case Coordinator &
Community Guide
for 200 & 204
entrants
(for 6 months)
& on request
for 202
Yellow Alert Public or Private
Bulk Billing
GP Clinic with
Refugee Interest
WH Hepatitis Clinic
RMH Infectious
Diseases Clinic
High
Complexity
200 & 204
Cases and
202 Cases
(on request)
PDMS rare but Visa
Medical Examination
conducted (including
health undertaking)
Foundation House
- Psych screening
assessment
447, 451, 695,
785, 786 & 070
Visas
Western
Hospital
TB Clinic
Latent TB
No TB
Refugee
Health
Nurse (RHN)
(where
present)
AMES
Community
Guide /
Access
Worker /
Volunteer
Support
arranges
appointments &
transportation
Community
Health Nurse
(CHN)
(where no
RHN
available)
202
Special
Humanitarian
(SHP) Entrant
Also Visas 201,
203, 866 are
eligible for
some services
TREATMENT &
FOLLOW-UP
FURTHER ASSESSMENT
WH Infectious
Diseases 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
CARE
PLANNING
Low
Complexity
200 & 204
Cases and
202 Cases
(on request)
Clinic
Nurse @
GP Clinic
or GP
RCH TB Clinic
Specialist
Medical
Within Hospital
or Health Centre
Radiology,
Pathology,
Pharmacy,
Immunology,
Counselling etc.
Specialist
Medical
Allied Health
(Dentist,
Optometrist,
Dietician,
Audiologist,
PT/OT etc)
RCH Immigrant
Screening Clinic
Combined
initial
assessment with
Refugee,
RHN or
CHN &
Interpreter
AMES
Community
Guide /
Access
Worker /
Volunteer
Support
arranges
appointments &
transportation
Public or
Private Bulk
Billing
GP Clinic
with
Refugee
Interest
Public Laboratory Testing
Centres (Radiology,
Pathology, Immunology)
Hospital
Specialist
or Public /
Private GP with
RHN / CHN
coordinates
further
assessments
AMES
Community
Guide /
Access
Worker /
Volunteer
Support
arranges
appointments &
transportation
Specialist
Women's
Health
Allied Health
(Dentist,
Optometrist,
Dietician,
Audiologist,
PT/OT etc)
Public /
Private GP
with RHN /
CHN and liaison
with AMES
Case
Coordinator
decide on
Care Plan
and
Treatment
Specialist
Mental
Health
Private Laboratory Testing
Centres (Radiology,
Pathology, Immunology)
Initial
assessment
with
Refugee &
Interpreter
Specialist
Women's
Health
Community
Support
Groups
Specialist
Mental Health
Foundation
House
- Intensive
Psych
assessment
Foundation
House
(Psychological
Counselling)
TOOLS
* 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
Community Health Centre
010
Asylum Seeker
(Bridging Visa
A or E)
Principles
underlying
success
of Health
Care
Pathway
Implementation
Hospital Emergency
Department
* Reduced
Duplication
All 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
Attempts to apply for Refugee Status
* Effective
Communication
& Feedback
AMES
* Holistic
Assessment &
* Complexity
Tool
* PreDeparture
Medical
Screen
(PDMS)
* 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
* Appropriate
Training &
Education
SCTT
* Service
Coordination
Plan
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
DRAFT
DRAFT
DRAFT
DRAFT
DRAFT
WestBay Alliance and Brimbank Melton PCPs
Refugee Health
Service Coordination Project
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
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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 the
• success of the Refugee Care Pathway:
•
•
•
•
•
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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