1. for refugees in countries of resettlement:
The impact of different models of primary health care on access, quality and coordination of care
for refugees in countries of resettlement:
A Systematic Review

2. Contributing authors and acknowledgements
Monash University: Grant Russell, I-Hao Cheng, Margaret Alston, Shiva Vasi & Sayed Wahidi
New South Wales Refugee Health Service: Mitchell Smith
The University of Ottawa: Kevin Pottie
The University of Queensland: Margaret Kay
The University of New South Wales: Mark F. Harris, Winston Lo & Bibiana Chan
The Australian Primary Health Care Research Institute for funding the study
I am a member of a large team which is listed here on the screen. I also want to acknowledge The Australian Primary Health Care Research Institute for funding the study

3. Refugee context Culturally and linguistically diverse
Increase in number in destination countries
Face inequities in the social determinants
of health
Multiple health care needs
Little synthesized data on what services are most appropriate
The refugees are culturally and linguistically diverse and their number is increasing in countries of resettlement. A report by the United Nations High Commissioner for Refugees showed that there in 2011, there was a 20% increase 20% in application for refugee status in the major developed countries compared to the previous year, reaching a figure of nearly 450,000.
Refugees face inequalities in the social determinants of health. They experience persecution, torture and other forms of trauma, deprivation, unhealthy environmental conditions and disrupted access to health care which results in their multiple health care needs that require specific attention.
Also, there is little synthesized data on what services are most appropriate for refugees and hence this systematic review was conducted.

4. Research Questions
What evaluated models of providing primary health care (PHC) to
resettled refugees in the countries of resettlement have been
described?
2. What is the impact of these PHC models on
a. Access to care
b. Coordination of care
c. Quality of care
The review had two major research questions. The first one was:
What evaluated models of providing primary health care (PHC) to resettled refugees in the countries of resettlement have been described?
The second question focussed on the access to care, coordination of care and the quality of care of these primary health care models for refugees.

5. Methods A narrative systematic review
Electronic sources: Medline, CINAHL, EMBASE, Cochrane Library, Scopus, Australian Public Affairs Information Service – Health, Health and Society Database, Multicultural Australian and Immigration Studies and Google Scholar
Grey literature: Sourced from stakeholder advisory committee, international advisers, networks in Australia and overseas
This was a narrative systematic review. This means that we firstly conducted a systematic review and then did a narrative synthesis of the findings. A narrative synthesis was needed as most of the studies were qualitative, and hence a meta-analysis not feasible.

6. Inclusion criteria Research paper with findings Published in English
Publication: 1990 – 2011
Papers  from major developed countries accepting refugees for long term resettlement
Papers evaluating existing primary heath care models or services for refugees
Papers were included if they were research findings, published in English between 1990 and 2011 from major developed countries and evaluating existing primary health care models or services for refugees.
(which are Australia, USA, Canada, Sweden, Norway, New Zealand, Finland, Denmark, Netherlands and the UK as defined by UNHCR)

7. Keywords used Refugee Primary Health Care Model of Care
Refugee, asylum seeker, transients and migrants, emigration and immigration
Refugee
Primary health care, primary care, general practice, general practitioner, community health nursing, community health, nursing service, community care, family medicine, allied service
Primary Health Care
Patient care, model, organization and management, model of care, health care delivery, medical care
Model of Care
We used three major key words: refugee,
primary health care and
model of care to identify papers for this review as can be seen in this figure.

8. Selection Process of Papers
2139 records identified in total
1383 records after de-duping, abstracts read
256 articles read in full
25 articles included
A total of 2139 articles were identified
we had 1383 articles after removing duplicates for which we scanned the titles and abstracts,
From this, we selected 246 articles to read in full
25 articles met all the inclusion criteria and were included in the review.

9. Result 1: Models of Care Service context Clinical model Workforce
Cost to clients
Health services
Non-health services
Now I will present the findings of the review. I will start with the results on models of care for the refugees which was divided into 6 major categories:
The service context included organisational structure, location of service, partnerships and media use.
The clinical model consisted of case management, care planning, outreach, health checks and referral pathways.
Workforce consisted of specialised workers, staff training, use of bilingual workers and interpreters, refugee workers, students and volunteers.
Cost to clients included services that were free or subsidized.
Health services included screening, prevention and immunisation services, mental health, dental health, physical health, allied health, medical specialist referral and health education.
Non-health services included transport, housing, education and information, art/dance and legal services.

10. Result 2a: Access Intervention focus Intervention models
Impact of intervention
Improving access to GP
Specialised workforce
+ GP registration
Specialised paediatric service
Media awareness of new service
+ Increased clinic attendance
Multiple services (health and non health)
Multidisciplinary approach to service;
Refugee health nurse;
Outreach;
Both male and female GPs
+ Utilisation of services
+ Staff of other organisations confident
in coordinating care with the centre
+ Client satisfaction
+ Interpreter access
+ Information on transport and on
accessing different services
16 papers evaluated the impacts of PHC models on the access to care by refugees.
In this table and the tables to come, plus means positive outcomes and minus means negative outcomes.
Specialised workforce was used to improve access to GP. Ethnic media was used to create awareness of a new specialised paediatric service. Multiple services including both health and non-health services were provided through the use of refugee health nurse, outreach, gender concordant GPs,

11. Access cont’ Intervention focus Intervention models
Impact of intervention
Multiple services (continued)
Longer consultations; Transport;
Patient advocacy; Partnerships; Education and information; Interpreting services;
Multilingual staff
± Coordination with different service providers
- Difficulty transferring patients to GPs due to GP
shortage and cost to patients
Cost, interpreter access, transport, unmet mental
health, dental and auditory needs
- Cultural competency in spite of receiving training
Time management for staff for longer
consultations
- Interpreting service non-representative and mode
- Access due to remote location
- Physical access for people with disability
longer consultation, patient advocacy, use of interpreters and multilingual staff, provision of information and education and free transport to attend medical appointments. The results of these studies showed that improved access was gained through outreach services, multidisciplinary staff, use of interpreters and bilingual staff, no-cost or low-cost services, free transport for appointments, longer consultation hours, patient advocacy and use of gender-sensitive providers.

12. Result 2b: Coordination
Intervention focus
Intervention models
Impact of intervention
Team coordination
Case management across multiple services
+ Patient satisfaction; access to
longer consultations;
interpreters and Australian Sign
Language fluent physician
Case management
Coordination across agencies by CHN/refugee health nurse/case manager providing assessment, coordinated care, liaison
+ Improved communication &
coordination between providers
+ Improved access to preventive
care (health checks,
immunisation)
6 papers evaluated the impacts of PHC models on the coordination of care for refugees.
The two major coordination models were team coordination and case management.
Team coordination was achieved by case management across multiple services. Case management used coordination across agencies by specialised workers like refugee health nurse, community health nurse, case manager who provided assessment, coordinated care and liaison.

13. Coordination cont’ Intervention focus Intervention models
Impact of intervention
Case management
(continued)
Cross-cultural training; Longer consultations; Education and information; Interpreting services; Multidisciplinary; Transport;
Outreach;
Patient advocacy
+ Utilisation of services
+ Information on transport and accessing different
services
+ Partner organisation report excellent collaboration
+ Client satisfaction
± Coordination with different service providers
- Bulk billing doctors
- Lack of local access transport
- Non-representative interpreters
- Staff dissatisfaction with waiting time
- Lack of awareness by some service providers
Cross cultural training of staff, longer consultation, provision of education and information, interpreters, transport, outreach and patient advocacy were provided in case management.
The results showed that improved coordination between different health care services and services responding to the social needs of clients was achieved through case management by a specialised worker and team approaches.

14. Result 2c: Quality of Care
Intervention focus
Intervention models
Impact of intervention
Case management
Training in cultural sensitivity;
Interpreters;
Whole community approach;
Multidisciplinary;
Multilingual staff;
Specialised refugee health nurses;
Network of providers with enhanced knowledge
+ Patient satisfaction
+ Reporting of physical and
psychological symptoms,
referral for medical and
psychological care
+ Other providers confident about
when to refer and
communication
+ Physical and mental health
17 papers evaluated the impacts of PHC models on the quality of care for refugees. The strategies used to improve quality of care were training to staff on cultural sensitivity, use of interpreters and multilingual staff, specialised refugee health nurse,

15. Quality of Care cont’ Intervention focus Intervention models
Impact of intervention
Case management
Medical students; Outreach;
Case managers for non health services; Transport;
Longer sessions;
Education and information;
Patient advocacy
+ Timely screening
+ Information useful on accessing transport and
other service
+ Access to preventive and curative heath care
- Bulk billing doctors
- Physical access (remote location and PWDs)
- Staff managing longer consultations
- Waiting lists
- Inadequate follow up, unnecessary referral
- Non representative interpreters
volunteers, outreach services, case managers for non-health services, provision of free transport, longer sessions, education and information and patient advocacy. The results depicted that improved quality of care was achieved through training in cultural sensitivity and appropriate use of interpreters.

16. An example
Refugee health nurse provides outreach at homes, schools, settlement services and GP practices.
Prevents service duplication.
(Kelly 2008)
“She helps the people get to the right clinic, at the right time with the right paperworks, ensures the right interpreter is present if required and that appropriate diagnostic tests have been performed and the results are available prior to the appointments.”
Let us look at an example from the study by Kelly 2008 in which a Refugee health nurse provided outreach at homes, schools, settlement services and GP practices. She prevented service duplication.
There is a nice quote in the study that summarises her work :
“The refugee health nurse helps the people get to the right clinic, at the right time with the right paperworks, ensures the right interpreter is present if required and that appropriate diagnostic tests have been performed and the results are available prior to the appointments.”

17. Another example
An asylum support nurse facilitated GP registration, conducted health check ups and acted as a conduit into primary care in general.
This resulted in most of the respondents being registered with a GP, had general health checks and fostered trusting relations between patients and services.
(O’Donnell et al, 2007)
I have yet another example from the study by O’Donnell et al, 2007 which tells about an asylum support nurse who facilitated GP registration, conducted health check-ups and acted as a conduit into primary care in general. This resulted in most of the respondents being registered with a GP, had general health checks and fostered trusting relations between patients and services.

18. Conclusion Improved access Improved quality of care
Improved coordination
Need for more high quality research evaluating models of care for refugees
Thus, the review identified components of PHC that improved access, quality and coordination of care and suggested for more high quality research evaluating models of care for refugees.

19. Conclusion cont’ Needs implications
Case management, especially by nurses
Pros – improves access and coordination
Cons – expensive & needs specialised training for staff
Outreach services
Refugee specific education and training to staff
Interpreters and bilingual staff
This study highlights the need of case management for the refugees. Case management, especially by nurses is a commonly used model which improves access and coordination. However it is potentially expensive and the case coordinator needs to have some specialised training. There is a need of outreach services, refugee specific education and training to staff and interpreters and bilingual staff in order to enhance the access, quality and coordination of care for the refugees.

20. Contact Details c.joshi@unsw.edu.au Professor Mark Harris
Ms Chandni Joshi