Introduction
Method
Terms | Definitions |
---|---|
Refugee | A refugee is a person forced to flee his or her home due to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, and who is unable or unwilling to return to his or her country of origin [2]. This includes humanitarian refugees with permanent residency visas, refugee asylum seekers (in community and detention), refugees with temporary protection visas. This review is primarily focused on refugees whose time since arrival in their country of resettlement is less than10 years. |
Primary health care | Primary care is the level of the health service system “that provides entry into the system for all new needs and problems. Primary care provides person-centred care over the continuum of time, assistance for all common conditions, and co-ordinates and integrates care provided by others” [19]. We take PHC to include care provided in the community settings through general practice, private and publicly funded community, allied health and nursing services and non-government organisations. Activities carried out in PHC include: |
• Assessment of health on arrival, including identification of infectious disease, mental health | |
• Ongoing management of acute or chronic illnesses, mental illnesses, psychosocial illnesses | |
• Provision of preventive care | |
• Referral to or links with more specialised medical services | |
• Referral, links to or provision of social care, housing, employment, education, or legal advice. | |
Model of care | A model of care describes the way in which a complex range of health services are organised and delivered [20]. This may be defined by principles (such as equity, accessibility, comprehensiveness, coordination), care delivery systems (e.g. multidisciplinary, on-line, the nature of consumers and the pathway of care which they must negotiate (e.g. entry, referral, etc.) and the range of services provided (e.g. medical specialist, generalist). These are underpinned by organisational and infrastructural elements which include: |
• health service funding/cost to clients/system: government, non-government organisation, private | |
• provider workforce: e.g. general practitioners, nurses, social workers, allied health | |
• organisation: team, network, integrated service | |
Access to the service | Access is the opportunity or ease with which consumers or communities are able to use appropriate services in proportion to their need [21]. As such it is influenced by both provider and consumer characteristics. Andersen described a model in which health care utilisation was determined by population and health system characteristics and influenced by patient satisfaction and outcomes [22]. The characteristics of PHC which determine their accessibility have been described by Pechansky (1981) [23] and more recently by Gulliford et al. [24] as: |
• Availability of a sufficient volume of services (including professionals, facilities and programmes) to match the needs of the population and the location of services close to those needing them | |
• Affordability (cost versus consumers’ ability to pay, impact of health care costs on socioeconomic circumstances of patients) | |
• Accommodation – the delivery of services in such a manner that those in need of them can use them without difficulty (e.g. appropriate hours of opening, accessible buildings) | |
• Appropriateness to socioeconomic, educational, cultural and linguistic needs of patients | |
• Acceptability in terms of consumer attitudes and demands | |
Coordination of care | This involves coordination of care between multiple providers and services with the aim of achieving improved quality of care and common goals for patients [25]. It may involve |
• Care planning | |
• Informal communication between workers or services | |
• Team meeting, case conferences, interagency meetings | |
• Shared assessments and records | |
• Coordination with non-health services including language services (interpreters, translated health information), formal settlement services, torture and trauma services | |
• Referral pathways and inter-service agreements | |
Quality of care | We define quality of care as the consistency of clinical care with recommendations in evidence-based guidelines as well as the quality of interpersonal care [26]. This includes patients’ satisfaction with aspects of care [27]. The Institute of Medicine has defined health care quality as the extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making [28]. It includes technical quality of primary and secondary prevention, and the management of chronic and acute conditions [29]. |
Case management | Case management has been variously defined. In this study we defined it as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost effective outcomes [30] |
Results
Study | Country of study | Components of the model | Impacts |
---|---|---|---|
Studies on access to health care only
| |||
Cheng et al. 2011 | Australia | Staff: Refugee health nurse, volunteers, multidisciplinary, multilingual. | Increased utilisation of services. |
Services: Orientation on health care system, interpreting, mental health, dental health, eye health, audiology, outreach, health checks, referral pathways, partnership, case management, care plan, medical specialist referral, accommodation. | |||
Sypek et al. 2008 | Australia | Services: Mental health, accommodation. | Barriers: cost, interpreter access, bulk billing doctors, unmet mental health needs, dental health and specialised auditory treatment. |
Geltman and Cochran 2005 | United States | Staff: Network of providers with enhanced knowledge on refugee health. | Timely health screening. |
Services: health screening and specialised medical service. | |||
Eytan et al. 2002 | Switzerland | Services: Health screening and interpreting | Increased referral to medical and psychological care. |
Ford 1995 | United States | Staff: Bilingual staff, | Increased use of preventive and curative care. |
Services: Outreach, referral pathway, no cost/subsidized, interpreting, health screening and immunization. | |||
Studies on coordination of care only
| |||
Mitchell 1997 | Australia | Staff: Multidisciplinary. | Good coordination among service providers. |
Services: Accommodation, patient advocacy, interpreting, health education and orientation about the Australian Healthcare system, mental health support, case management, outreach, medical specialist referral. | |||
Studies on quality of care only
| |||
Grigg-Saito et al. 2010 | United States | Staff: Interpreting, cultural competency training to staff, outreach. | Improved physical and mental health status. |
Services: bilingual community health workers, multidisciplinary. | |||
Gould et al. 2010 | Australia | Staff: Multidisciplinary, network of providers. | Timely medical care. |
Service: Health screening, referral to specialists, interpreting, no cost, dental health, transport, orientation on health care system. | |||
Birman et al. 2008 | United States | Staff: Multidisciplinary and bilingual. | Improved mental health. |
Services: Mental health, case management, patient advocacy, referral, interpreting, transport, outreach. | |||
Goodkind 2005 | United States | Staff: Students. | Improved mental health. |
Services: Mental health, interpreting, outreach. | |||
Fox et al. 2005 | United States | Staff: Bilingual. | Improved mental health. |
Services: Mental health. | |||
Barrett et al. 2000 | Australia | Staff: Bilingual. | Service culturally acceptable, reduced levels of anxiety. |
Services: Mental health, interpreting. | |||
Clabots and Dolphin 1992 | United States | Services: Multilingual video tapes to provide health education and information on how to access the health care system | Culturally sensitive and appropriate for clients. |
Studies on access and coordination of care
| |||
Australian Resource Centre for Healthcare Innovations 2009 | Australia | Staff: Network of providers with enhanced knowledge on refugee health, multidisciplinary, refugee health nurse. | Improved access to preventive care (health checks and immunisation), improved communication and coordination between providers. |
Services: Education and information, partnership, referral pathway, case management, health checks, medical specialist referral, immunization and preventive care. | |||
Kelly 2008 | Australia | Staff: Refugee health nurse. | Improved access to primary health care and specialist services, increased number of patients from refugee backgrounds, good coordination among services. |
Services: Outreach, no or low cost, dental health, optometry, transport, patient advocacy. | |||
Studies on access and quality of care
| |||
Department of Health and Human Services, 2010 | Australia | Staff: multilingual staff, refugee health nurse. | Increased use of interpreters and culturally aware staff. |
Services: Education and information, interpreting, community advocacy, case management, mental health, health screening, referral pathways, specialist medical treatment. | Difficulty accessing refugee health nurse, bicultural workers, culturally appropriate interpreters and mental health services. | ||
Companion House 2009 | Australia | Services: Mental health. | Improvement in mental health, difficulty accessing medicines due to cost. |
Sheikh and MacIntyre 2009 | Australia | Services: Media awareness of health service, health education. | Increased clinic attendance and enhanced knowledge on preventive care. |
Smith 2009 | Australia | Staff: Refugee health nurse, multilingual staff, both male and female GPs. | Client satisfaction with multilingual staff. Ineffective referral to non-health services, lack of mental health service, non-representative interpreters. |
Services: Patient advocacy, interpreting, case management, outreach, health education, transport, education and information, partnership, dental health and allied health. | |||
O’Donnell et al. 2007 | United Kingdom | Staff: Asylum support nurse for coordination with health service and conducting health checks. | Increased GP registration, trust built between patients and health services. |
Pottie and Hosland 2007 | Canada | Staff: Medical students. | Patient satisfaction, increase in trust between patients and health care providers, increased knowledge of health system and easier access. Interpreter service was not reliable. |
Services: Orientation on health care system, outreach, health education, students trained in cultural sensitivity, health and social support. | |||
Samaan 2004 | Australia | Staff: Volunteers. | Client satisfaction with onsite interpreters and patient advocacy. |
Services: Outreach, interpreting services, transport, patient advocacy, longer consultation sessions with GP, partnership, health check, immunisation, mental health, dental health, eye health, allied health, case management, no cost, referral pathways. | |||
Barriers: cost, lack of local transport | |||
Interpreter access, non-representative interpreting, lack of bulk billing doctors, difficulty in physical access for people with disabilities and remote location. | |||
Studies on access, coordination and quality of care
| |||
Department of Health 2011 | Australia | Staff: Refugee health nurse. | Enhanced access to services, culturally appropriate service, good coordination among services and continuum of care. |
Services: Mental health, dental health, eye health, health assessment, referral to specialist services, English classes, interpreters, accommodation. | |||
Robson 2011 | Australia | Staff: Refugee health nurse. | Client satisfaction, staffs of other organisation confident on coordinating care with the centre, increased access to preventive care. |
Services: Outreach, patient advocacy, partnership, referral pathway, medical specialist referral, health screening, immunisation, case management, health education, optometry, audiology, mental health, dental health, allied health. | |||
Western Region Health Centre 2001 | Australia | Staff: Refugee health nurse. | Clients satisfied about information on accessing different services including transport. |
Services: Partnerships, orientation on the health care system, information on rights, entitlements and services available and how to access them, longer consultation, training in cultural sensitivity to staff, interpreting, referral pathway, allied health. | Problems with cultural competency in spite of receiving training, time management for staffs due to longer consultations and dissatisfaction with long waiting time, inadequate follow up, unnecessary referrals in absence of interpreters, interpreting service non-representative. | ||
Coordination with some service providers was good while there was a lack of coordination with many of them. |
Models of care
Main characteristics | Evaluated components of the models | List of studies | |
---|---|---|---|
Service context | Organisational | Specialist service | Ford et al. 1995 |
Part of a hospital | Sypek et al. 2008; Samaan 2004 | ||
Location | Urban | Cheng et al. 2011; Department of Health 2011; Grigg-Saito et al. 2010; Australian Resource Centre for Healthcare Innovations 2009; Sheikh & MacIntyre 2009; Smith 2009; Birman et al. 2008; Fox et al. 2005; Eytan et al. 2002; Western Region Health Centre 2001; Mitchell 1997; Clabots and Dolphin 1992 | |
Rural | Gould et al. 2010; Sypek et al. 2008 | ||
State | Department of Health and Human Services 2010; Samaan 2004 | ||
Partnerships | Cheng et al. 2011; Robson 2011; Australian Resource Centre for Healthcare Innovations 2009; Smith 2009; Samaan 2004; Western Region Health Centre 2001 | ||
Media | Sheikh & MacIntyre 2009 | ||
Clinical model | Case management | Robson 2011; Department of Health and Human Services 2010; Australian Resource Centre for Healthcare Innovations 2009; Smith 2009; Birman et al. 2008 Samaan 2004; Cheng et al. 2011; Western Region Health Centre 2001; Mitchell 1997 | |
Care planning | Cheng et al. 2011 | ||
Outreach | Cheng et al. 2011; Robson 2011; Grigg-Saito et al. 2010; Smith 2009; Birman et al. 2008; Kelly 2008; Pottie & Hosland 2007; Goodkind 2005; Samaan 2004; Mitchell 1997; Ford et al. 1995 | ||
Health checks | Cheng et al. 2011; Robson 2011; Australian Resource Centre for Healthcare Innovations 2009; O’Donnell et al. 2007 | ||
Referral pathways | Cheng et al. 2011; Robson 2011; Australian Resource Centre for Healthcare Innovations 2009; Samaan 2004; Western Region Health Centre 2001; Ford et al. 1995 | ||
Workforce | Specialised workers (refugee nurses) | Cheng et al. 2011; Robson 2011; Department of Health and Human Services 2010; Australian Resource Centre for Healthcare Innovations 2009; Smith 2009; Kelly 2008; O’Donnell et al. 2007; Western Region Health Centre 2001 | |
Training (cross-cultural) | Grigg-Saito et al. 2010; Pottie & Hosland 2007; Western Region Health Centre 2001 | ||
Bilingual workers, interpreters | Cheng et al. 2011; Department of Health and Human Services 2010; Grigg-Saito et al. 2010; Smith 2009; Birman et al. 2008; Fox et al. 2005; Goodkind 2005; Samaan 2004; Eytan et al. 2002; Barrett et al. 2000; Mitchell 1997; Ford et al. 1995; Clabots and Dolphin 1992 | ||
Students and volunteers | Cheng et al. 2011; Pottie & Hosland 2007; Goodking 2005; Samaan 2004 | ||
Cost to clients | No-cost or subsidised | Gould et al. 2010; Kelly 2008; Samaan 2004; Ford et al. 1995 | |
Health Services | Screening/prevention | Robson 2011; Department of Health and Human Services 2010; Gould et al. 2010; Geltman and Cochran 2005; Samaan 2004; Ford et al. 1995 | |
Mental health | Cheng et al. 2011; Robson 2011; Department of Health and Human Services 2010; Companion House 2009; Birman et al. 2008; Sypek et al. 2008; Fox et al. 2005; Goodkind 2005; Samaan 2004; Barrett et al. 2000 | ||
Dental health | Cheng et al. 2011; Department of Health 2011; Robson 2011; Gould et al. 2010; Smith 2009; Kelly 2008; Samaan 2004 | ||
Physical: general practitioner, eye, maternal and child health, infectious disease/immunisation | Cheng et al. 2011; Department of Health 2011; Robson 2011; Australian Resource Centre for Healthcare Innovations 2009; Sheikh & MacIntyre 2009; Kelly 2008; Samaan 2004; Western Region Health Centre 2001; Ford et al. 1995 | ||
Allied health | Cheng et al. 2011; Robson 2011; Smith 2009; Samaan 2004; Western Region Health Centre 2001 | ||
Medical specialist referral | Cheng et al. 2011; Department of Health 2011; Robson 2011; Gould et al. 2010; Australian Resource Centre for Healthcare Innovations 2009; Mitchell 1997 | ||
Health education | Robson 2011; Sheikh & MacIntyre 2009; Smith 2009; Pottie and Hosland 2007; Mitchell 1997; Clabots and Dolphin 1992 | ||
Non-health services | Transport | Gould et al. 2010; Smith 2009; Birman et al. 2008; Kelly 2008; Samaan 2004; | |
Housing | Cheng et al. 2011; Department of Health 2011; Sypek et al. 2008; Mitchell 1997 | ||
Education and information | Cheng et al. 2011; Department of Health and Human Services 2010; Gould et al. 2010; Australian Resource Centre for Healthcare Innovations 2009; Smith 2009; Pottie & Hosland 2007; Western Region Health Centre 2001; Mitchell 1997; Clabots and Dolphin 1992 | ||
Patient advocacy | Robson 2011; Department of Health and Human Services 2010; Smith 2009; Birman et al. 2008; Kelly 2008; Samaan 2004; Mitchell 1997 |
Impact on access
Impact on coordination
Impact on quality of care
Discussion
-
Increasing awareness and health literacy in using health services with interventions involving media and health education.
-
Outreach to facilitate registration or clinic attendance.
-
Improving acceptability and appropriateness through the use of interpreters and bilingual workers.
-
Coordinating service networks (often facilitated by refugee health nurses) to improve access to range of services and to transport.
-
Reducing cost to clients by use of pro bono providers or not using co-payments.