Background
Objectives
Methods
Study design
Study setting
Sample
Intervention
Development of the intervention
Regional Partnership | Academic Institutions | Primary Health Organisations | Refugee Focused Health Services | Settlement agencies | State based organisations | National organisations |
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South East Melbourne | Monash University | Enliven Victoria 2016–2017: South Eastern Health Providers Association | Monash Health Refugee Health and Wellbeing | AMES Australia | Victorian Department of Health and Human Services Victorian Refugee Health Network | Royal Australian College of General Practitioners Refugee Health Network of Australia |
North West Melbourne | La Trobe University | North Western Melbourne PHN. | cohealth | |||
South West Sydney | University of New South Wales | South Western Sydney PHN. | NSW Refugee Health Service | Settlement Services International | NSW Refugee Health Service |
Activity | Description |
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Cultural awareness | Practice staff demonstrate cultural awareness and sensitivity to refugee issues, including an understanding of the refugee experience. |
Communication skills | GPs and practice nurses have appropriate communication skills (They are sensitive to the needs of refugees and take time to explain care to patients so they can make informed decisions by understanding what is happening as part of their care). |
Business practices | practice staff are knowledgeable about and use business practices (including longer appointments, booking appointment with specific GP, Medicare billing, etc.) to support conduct of refugee health assessments |
Information sharing | Practice has in place clear processes for sharing relevant patient information with other services. Practice staff use these processes consistently when receiving patient information and obtaining patient information. |
Follow up on referrals | Practice staff refer clients to appropriate services and check whether the client attended the service. (If the problem is urgent or clinically significant this follow up may be with the receiving service, otherwise, follow-up will occur when patient re-attends the clinic) |
Clinical matters | Practices may also identify other areas related to the clinical care of refugees. GPs and practice nurses may choose to learn more about the diagnosis and management of specific refugee health issues, e.g. refugee catch-up immunisation, mental health, paediatric health, infectious diseases. |
Intervention process
Intervention providers
Outcomes
Participant timeline
Month | Pre-intervention | 1st month Facilitation | 2nd Facilitation | 3rd Facilitation | 4th Facilitation | 5th Facilitation | 6th Facilitation | 7th mth | 8th | 9th | 10th | 11th | 12th m | 13th | ||
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July – August & ongoing as required | August ongoing | Grp 1 September + | Oct + | November + | December + | January + | Feb + | March + | April | May | Jun | July | August | Sept 2018 + | ||
Grp 2 March 2018 + | Apr + | May + | Jun + | July + | Aug + | Sept + | Oct | Nov | Dec | Jan | Feb | March 2019 + | ||||
Activity | Recruitment of 12 practices | Baseline data collection (with all practices following consent) | Practice facilitation visit #1 (Doesn’t commence until consent confirmed, & practice survey completed) | Follow up and phone call #1 | Practice facilitation visit #2 | Follow up phone call #2 | Practice facilitation visit #3 | Follow up phone call #3 | Post intervention data collection | Practices conduct business as usual | 6-month post intervention data collection | |||||
Description | Includes all contact up to the point of gaining informed consent from the practice and staff (GPs, nurses and others). Open and targeted invitations. Informed by RHN, RHFs, others. EOI form completed & eligibility checked. | Randomise practices to immediate start or wait. Visit ALL practices as they are recruited to finalise consent and confirm data collection processes, including PEN CAT and TIS. Make appointments for PENCAT data collection Sign consent form for TIS data Commencing Practices Explain to practice manager that on line surveys must be completed before facilitation can commence: -Practice survey -Clinicians: at least 50% of GPs. WAITING practices (6 month wait): RO Also Completes Refugee healthcare survey with practice team. Facilitator not present. | Step 1. Pre intervention refugee healthcare (RHC) survey conducted by RO with practice team to identify potential areas for action Facilitator observes and takes notes to assist them with step 2. Step 2. Facilitator leads discussion with practice team informed by the RHC interview and practice description survey. Purpose is to a) identify and discuss action areas aligned to intervention priorities, b) to commence action plan development WAITING practices (6 month wait): Refugee healthcare survey is REPEATED with practice team and step 2 undertaken when they commence facilitation. | Prior to phone call send practice draft action plans (based upon learnings from refugee health survey) The practice reviews action plans, edit if required and return to facilitator. Practice implements action plans. Phone Call- Review progress with action plan development and early challenges with action plan implementation. | Provide support for action plan development and implementation and monitor implementation | Provide support for action plan implementation and monitor implementation Document changes to the action plan that have occurred. | Provide support for action plan implementation and monitor implementation Document changes to the action plan that have occurred. | Provide support for action plan implementation and monitor implementation Document changes to the action plan that have occurred. | PENCAT data extraction Post intervention RHC survey | New practices & procedures operate | PENCAT data extraction Post intervention RHC survey/ interview |
Sample size
Recruitment
Assignment of interventions
Allocation
Blinding
Data collection methods
Practice Description Survey | Refugee Health Survey | Provider Survey | PENCS CAT4™ extract | |
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Pre-intervention (Baseline) | xa | x | x | x |
Post-intervention | – | x | x | x |
6-months post intervention | – | – | – | x |
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De-identified data extraction: The PENCS CAT4™ tool, is widely used by practices and Primary Health Networks to monitor practice performance and inform routine quality improvement interventions. The research team designed an add-on software report within the CAT4™ tool to allow measurement of general practice performance in key refugee health quality domains including refugee identification, interpreter use and health/mental health assessments. Searches of each participating practice’s electronic clinical and practice management software will first filter all patient records where identifiers of country of birth, ethnicity or language spoken that are relevant to refugee populations have been recorded in a coded field or as free text in the patient record. All identifiable information including patient name, address, contact details will be automatically removed prior to the output being made available to the researchers. This output will be a de-identified line listed excel spreadsheet that includes (where available) residential postcode, age, gender, country of birth, ethnicity, language spoken, year of arrival, interpreter needed, list of diagnoses, date of first visit, dates of visits in the last 12 months, dates of visits where an interpreter was used, date of last health assessment and date of last mental health care plan. This data extract will be carried out at baseline and repeated at the end of the intervention period as well as at 6-months post intervention completion. Analysis will allow us to identify track changes in practice performance as a result of the quality improvement intervention.
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A Practice Description survey (Additional file 2) will be administered to the practice team at baseline and will contain questions regarding a practice’s staffing, patient load and demographics, organisational structure/governance, appointment setting systems, clinical record management systems, payment systems and processes for client transition including transfer of information. Survey items were primarily derived from the Preventive Evidence into Practice study (PEP) [33] and the Canadian Community-Based Primary Health Care Common Indicator Project [36].
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A Practitioner survey (Additional file 3) will be administered to each consenting general practitioner. This will contain questions ascertaining practice staff’s background, experience and interest in refugee health care delivery, and experience of and attitude towards using interpreters in clinical care. Survey items were derived from the Comparison of Models of Primary Care in Ontario study [37]; PEP [33]; the Community-Based Primary Health Care Common Indicator Project [36]; and the Patient-Centered Medical Home Scale [38]. The survey will be repeated at the end of the intervention period.
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A Refugee healthcare survey (Additional file 4) will be administered to each practice and their staff participating in the project by the Research Officer during the first facilitation visit to document whole-of-practice approaches to refugee care. The survey items were designed specifically for this project, informed by the areas of focus emerging from the deliberative forum. The data generated by using this tool will also inform tailoring of the practice facilitation intervention. The survey will be repeated at the end of the intervention period.
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Semi-structured interviews: Following the intervention period, we will interview Practice Facilitators (n = 3), research officers (n = 3) and practice staff who played a key role in intervention from two practices in each round within each region (n = 12 practices) to explore their experiences of being involved in the intervention. The aims of the interviews are to identify key factors affecting the fidelity, effectiveness and sustainability of the intervention.
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Facilitator diary: Practice Facilitators will maintain a reflective diary of their contacts with practices to document activities undertaken, resources provided, challenges encountered and how these were overcome.
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Action plans: As part of the intervention, Practice Facilitators will work alongside key practice personnel to document practice goals and relevant activities relating to refugee identification, interpreter use, conduct of comprehensive health assessments and referral. Action plans will be used to monitor progress towards practice goals and (where applicable) the documentary evidence of achieving these goals.
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Facilitator meeting minutes: The research team will maintain detailed minutes from the research officers’ meeting and the Practice Facilitator meetings.
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Reports of regional needs assessments: Will provide additional information on the region, including refugee population demographics, distribution general practice clinics and refugee health services within the catchment and socio-political factors affecting service provision.
Data management
Statistical methods
Qualitative analysis
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Practice outer context: refugee background population in the area, links with external environment.
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Practice inner context: practice size, practice staff, time required to recruit the practice, proportion of refugee patients, staff/patient language concordance.
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Intervention: practice’s level of engagement with the intervention.
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Facilitator and research officers: the time research officers spend engaging the practices and troubleshoot issues arising with implementation.