WestBay Alliance & Brimbank Melton PCP Care Planning for Refugee Health An Evolving Model
Dec 18, 2015
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