Completion of Primary Care Referrals Among New York State Refugees

An important component of the New York State Refugee Health Program’s (NYSRHP) mission is to ensure refugees with identified medial conditions are referred to primary and specialty care. A programmatic evaluation was conducted to assess the completion rate for primary care referral appointments made during the initial domestic health assessment among refugees in NYS (exclusive of New York City). Upon arrival in NYS, refugees may receive a domestic health assessment by one of NYSRHP contracted providers. As part of the assessment, referrals for primary and specialty care may be assigned. From July 2010 to June 2011, 69 % of NYS-bound refugees that received a primary care referral by a NYSRHP contracted provider completed their appointment.     

A comparative cost analysis of the Vaccination Program for US-bound Refugees

BackgroundVaccination Program for US-bound Refugees (VPR) currently provides one or two doses of some age-specific Advisory Committee on Immunization Practices (ACIP)-recommended vaccines to US-bound refugees prior to departure.MethodsWe quantified and compared the full vaccination costs for refugees using two scenarios: (1) the baseline of no VPR and (2) the current situation with VPR. Under the first scenario, refugees would be fully vaccinated after arrival in the United States. For the second scenario, refugees would receive one or two doses of selected vaccines before departure and complete the recommended vaccination schedule after arrival in the United States. We evaluated costs for the full vaccination schedule and for the subset of vaccines provided by VPR by four age-stratified groups; all costs were reported in 2015 US dollars. We performed one-way and probabilistic sensitivity analyses and break-even analyses to evaluate the robustness of results.ResultsVaccination costs with the VPR scenario were lower than costs of the scenario without the VPR for refugees in all examined age groups. Net cost savings per person associated with the VPR were ranged from $225.93 with estimated Refugee Medical Assistance (RMA) or Medicaid payments for domestic costs to $498.42 with estimated private sector payments. Limiting the analyses to only the vaccines included in VPR, the average costs per person were 56% less for the VPR scenario with RMA/Medicaid payments. Net cost savings with the VPR scenario were sensitive to inputs for vaccination costs, domestic vaccine coverage rates, and revaccination rates, but the VPR scenario was cost savings across a range of plausible parameter estimates.ConclusionsVPR is a cost-saving program that would also reduce the risk of refugees arriving while infected with a vaccine preventable disease.     

Refugees and health care--the need for data: understanding the health of government-assisted refugees in Canada through a prospective longitudinal cohort

Canada is a country with large populations of immigrants and refugees. These populations face unique health challenges and barriers to accessing health care services. Amendments to the Canadian Immigration and Refugee Protection Act in 2002 have resulted in an increase in refugees with complex medical needs. However, little is known about the health of refugees on arrival and their subsequent health care trajectories. There is an urgent need for an improved understanding of refugee demographics and health status on arrival, changes in health status over time, utilization of health services, and characteristics associated with optimal health outcomes. This knowledge gap could be addressed through the creation of a longitudinal cohort study of government-assisted refugees (CARs) in British Columbia (BC). The provision of services for CARs in BC lends itself readily to the creation of a prospective CAR cohort. This, combined with access to highly reliable, valid and comprehensive administrative databases available through Population Data BC, would allow for longitudinal follow-up, and ensure low attrition rates. Establishment of such a cohort would improve knowledge of refugee health and could guide health service providers and policy-makers in providing optimal services to GARs.     

A comprehensive refugee health screening program

Nationally and internationally, there is a struggle to provide adequate health screening and assessment programs for refugees. The Department of Family Medicine at the University of Colorado Health Sciences Center in partnership with the Colorado Refugee Services Program has developed a comprehensive refugee health screening and assessment program. The program was designed to ensure access to screening and to provide better care for this vulnerable population. Key features of the program include a single point of access for all family members, full availability of appropriate interpreting services, comprehensive health assessments that include a thorough mental health screening, data collection and evaluation, and education of health care providers to deliver culturally responsive care. During the first 30 months of this program, comprehensive assessments were provided for more than 1600 refugees. Future directions include improving the efficiency of daily systems, seeking alternative sources of funding, improving follow-up and vaccination rates, expanding mental health services, and tracking health outcomes and refugees' utilization of health care services through longitudinal research.     

Factors Associated with Refugee Acute Healthcare Utilization in Southern Connecticut

Our objective was to examine refugees’ acute care use early in resettlement. We conducted a retrospective cohort study of acute care use, emergency room and hospital visits, by adult refugees arriving in Southern Connecticut between 2/1/2013 and 2/1/2015. We examined associations between any acute care use and collected demographic as well as health characteristics. Of the 248 refugees in our sample, 57% had a medical evaluation within 30 days of arrival. 102 (41%) had at least one acute care visit within 8 months of arrival. Male sex (OR 1.90, 95% CI 1.09–3.30) and prior history of hypertension (OR 2.87, 95% CI 1.06–7.33) were associated with greater likelihood of an acute care visit within 8 months of arrival, while having a medical evaluation within 30 days of arrival was associated with lower likelihood (OR 0.56, 95% CI 0.32–0.98). Designing systems to ensure timely evaluations of newly arrived refugees may reduce frequent acute care utilization.     

Evaluating Complex Health and Social Care Program Using Multi-Criteria Decision Analysis: A Case Study of “Better Together in Amsterdam North”

ObjectivesMulti-criteria decision analysis (MCDA) has been recommended to support policy making in healthcare. However, practical applications of MCDA are sparse. One potential use for MCDA is for the evaluation of programs for complex and vulnerable patients. These complex patients benefit from integrated care programs that span healthcare and social care and aim to improve more than just health outcomes. MCDA can evaluate programs that aim to improve broader outcomes because it allows the evaluation of multiple outcomes alongside each other. In this study, we evaluate an innovative integrated care program in the Netherlands using MCDA.MethodsWe used an innovative MCDA framework with broad outcomes of health, well-being, and cost to evaluate the Better Together in Amsterdam North (BSiN) program using preferences of patients, partners, providers, payers, and policy makers in the Netherlands. BSiN provides case management support for a period of 6 months. Seven outcomes that previous research has deemed important to complex patients were measured, including physical functioning and social relationships and participation.ResultsWe find that the program improved the overall MCDA score marginally, and, thus, after 6 and after 12 months, BSiN was preferred to usual care by all stakeholders. BSiN was preferred to usual care, mostly owing to improvements in psychological well-being and social relationships and participation.ConclusionsThe integrated healthcare and social care program BSiN in the Netherlands was preferred to usual care according to an MCDA evaluation. MCDA seems a useful method to evaluate complex programs with benefits beyond health.     

Health Care Utilization of Refugee Children After Resettlement

Refugee children can have significant health problems. Our objective was to describe health status and health care utilization of refugee children after resettlement. A retrospective chart review of refugee children was performed. Initial laboratory data was extracted. Primary care visits, emergency room visits, and subspecialty referrals in the first 15 months from arrival were recorded. The sample included 198 refugees, many with positive initial screening tests. After arrival, 21% had an emergency department visit, 40% had a primary care sick visit, and 71% had a primary care follow-up. Mean number of visits ranged from 0.3 for emergency department to 1.9 for follow-up. Fifty-seven percent were referred to at least one subspecialist. Refugee children had substantial disease burden at arrival. Most had primary care follow-up visits and subspecialty referral after resettlement. These visits were largely for problems identified on initial screening and for general pediatric illnesses.     

"Good help" in St. Petersburg

Founded in 2001 by representatives of seven local organizations, the Refugee Healthcare Partnership (RHP) provides necessary health services and meaningful employment opportunities for refugees in the Tampa Bay, FL, area. Spearheaded by Catholic health care organizations and Catholic Charities of the Diocese of St. Petersburg, the RHP was made possible initially by funding from the Bon Secours Mission Fund of Bon Secours Health System, Marriottsville, MD. Florida leads the nation in granting lawful permanent resident status to refugees and asylum seekers. Like the rest of the country, Florida has a shortage of long-term care nursing personnel. RHP leaders believed that by training refugees to become certified nursing assistants (CNAs) they could ease the local CNA shortage and provide refugees jobs with health insurance. Soon thereafter, RHP leaders recognized that to be successful they would have to provide services to teach refugees English. The RHP worked with the Pinellas Technical Education Centers (PTEC) to form the Pinellas Refugee Education Program (PREP). Funded by the Florida Department of Children and Families and the U.S. Department of Health & Human Services, PREP assists refugees to learn English and to train for jobs, including careers outside of health care. To help RHP clients prepare for CNA classes at PTEC, a "medical orientation" course was developed to give refugees familiarity with medical terms and with long-term care practices in the U.S. In less than four years, the RHP has served more than 260 clients. The RHP continues to offer its clients needs assessment; placement in health-care related, entry-level training programs; mentoring programs; and referrals to medical services. The original seed funding from Bon Secours has now been superseded by a substantial grant from the state.     

Vaccine delivery to newly arrived refugees and estimated costs in selected U.S. clinics, 2015

BackgroundNewly arrived refugees are offered vaccinations during domestic medical examinations. Vaccination practices and costs for refugees have not been described with recent implementation of the overseas Vaccination Program for U.S.-bound Refugees (VPR). We describe refugee vaccination during the domestic medical examination and the estimated vaccination costs from the US government perspective in selected U.S. clinics.MethodsSite-specific vaccination processes and costs were collected from 16 clinics by refugee health partners in three states and one private academic institution. Vaccination costs were estimated from the U.S. Vaccines for Children Program and Medicaid reimbursement rates during fiscal year 2015.ResultsAll clinics reviewed overseas vaccination records before vaccinating, but all records were not transferred into state immunization systems. Average vaccination costs per refugee varied from $120 to $211 by site. The total average cost of domestic vaccination was 15% less among refugees arriving from VPR- vs. nonVPR-participating countries during a single domestic visit.ConclusionOur findings indicate that immunization practices and costs vary between clinics, and that clinics adapted their vaccination practices to accommodate VPR doses, yielding potential cost savings.     

Factors Influencing Dietary Practices Among Ghanaian Residents and Liberians Living in a Protracted Refugee Situation in Ghana

ObjectiveExamine dietary practices among Liberian refugees living in a protracted refugee situation and Ghanaians living among them.DesignQualitative data were collected via audio-taped in-depth interviews as part of a larger mixed-methods cross-sectional study.SettingBuduburam Refugee Settlement and neighboring villages, Ghana.ParticipantsTwenty-seven Liberian and Ghanaian women aged ≥16 years, who lived with ≥1 other female generation.Phenomenon of InterestSimilarities and differences in factors influencing dietary practices among Liberian refugees living in Buduburam Refugee Settlement and Ghanaians living in and around this settlement.AnalysisDomains, themes, and subthemes were confirmed through a highly iterative coding and consensus process. ATLAS.ti (version 7.5.10) was used to finalize coding and extract quotations.ResultsSeven domains emerged forming direct and indirect pathways influencing dietary patterns among Liberian refugees and Ghanaians: social support, food availability, nutrition knowledge, cultural food beliefs, food access, food preparation, and national identity.Conclusions and ImplicationsFindings provide important insights into crucial factors driving dietary practices among refugees and local communities in and around a former protracted refugee settlement. Results strongly suggest that nutrition education, food availability, and access issues should be addressed with culturally sensitive programs targeting both the refugee and host communities.     

The development of a transition medical home utilizing the individualized transition plan (ITP) model for patients with complex diseases of childhood

BackgroundAdvances in medicine and technology, have enabled greater numbers of children with complex illness to survive into adulthood. Adolescents with these conditions are at high risk for adverse outcomes when transitioning to adult health care. The “Staging Transition for Every Patient” (STEP) Program was developed to systematically improve the transition from pediatric to adult healthcare.ObjectiveThis article details the development of the STEP program and the novel use of “Individualized Transition Plans” (ITP) in the clinic setting.MethodsA provider needs’ assessment of the existing transition services among youth with specific diagnoses was performed, a steering committee was developed that created a transition policy, and a medical home within the adult system was established with an interdisciplinary approach. The ITP focuses on 5 individualized goals, it was developed and tested with the first-year cohort of patients.ResultsIn the initial needs assessment, 7 of 35 diagnoses were found to have an effective transition plan. The STEP program partnered with departments across the adult facility to conduct 267 interdisciplinary patient visits. In the first year, 169 new patients were seen in the clinic. The average age was 23.0 ± 4.1 years old. The ITP goals included referrals to adult specialists, advanced care planning, career and education, transition readiness, caregiver burden, and an emergency sick plan.ConclusionThere is a need for organized transition care for medically complex youth. The STEP program answers that need by addressing the unique needs of each patient. Individualized transition planning builds trust and addresses multiple domains of health.     

Mental health screening in a refugee population: a program report

Over the past 10 years the United States has resettled an average of 106,500 refugees annually (U.S. Committee for Refugees: Refugee Rep 1999; 20(12):1–12), relocating them to various cities across the country. Upon arrival, some states offer refugees physical health screening, specifically for communicable diseases such as tuberculosis, intestinal parasites and Hepatitis B, and for general preexisting medical problems. Unfortunately, the same attention is rarely given to potential mental health needs. Research has shown that refugees are at greater risk for depression, anxiety, and posttraumatic stress syndrome than the general U.S. population, yet they are not routinely screened. The purpose of this paper is to describe the addition of an innovative program for mental health screening in a refugee population. The current study found that mental health screening was more effective when done in a home visit situation. A 23.8% rate of depression was found amongst those refugees screened.     

The Role of Immigrant Admission Classes on the Health and Well-being of Immigrants and Refugees in Canada: A Scoping Review

Many countries offer different pathways through which migrants can enter a new country. In Canada, there are three main immigrant admission classes: economic, family, and refugee. Previous research suggests that there are differences in health outcomes among various subgroups of migrants. A scoping review was conducted to characterize the role of immigrant admission classes on the health and well-being of immigrants and refugees in Canada. MEDLINE, Embase, PsycINFO, Sociological Abstracts, and EconLit databases were searched for quantitative studies published in English after 1990. The screening and selection process identified 27 relevant studies. Studies were categorized into four key reported outcomes: health care and services utilization, self-rated health and mental health, medical conditions and chronic illnesses, and social integration and satisfaction. Findings confirm that certain subgroups have worse health outcomes after arrival, particularly refugees, family class and other dependent immigrants. Health outcomes vary significantly across immigrant subgroups defined by the admission class through which they entered Canada.

     

Nutritional Status of Refugee Children Entering DeKalb County,Georgia

This study determines the nutritional status among refugee children entering one of the largest resettlement counties in the United States and identifies differences between incoming populations. Medical records of all newly arriving pediatric refugees (0–18 years) entering DeKalb County, Georgia between October 2010 and July 2011 were reviewed. Refugee children were grouped as African, Bhutanese, or Burmese (resettling from either Thailand or Malaysia) for comparative analysis. Approximately one in five refugees were anemic or malnourished, while a quarter had stool parasites, and nearly half had dental caries. African refugees had the highest anemia but the lowest underweight prevalence (p < 0.05). Compared to Burmese resettling from Malaysia, Burmese children from Thailand had a higher prevalence of anemia, underweight, and stool parasites (p < 0.05). Clinicians should use CDC medical screening guidelines for newly arriving pediatric refugees, as well as ensure proper nutritional support and follow-up care.     

Barriers and facilitators of immunisation in refugees and migrants in Australia: an east-African case study

BackgroundImmunisation programs available in low and middle-income countries include fewer vaccines in comparison to Australia’s National Immunisation Program. As a result, refugees and migrants may have a heightened risk of being inadequately immunised upon arrival to Australia. Several studies have suggested that East African immigrants have low vaccination coverage. As such, the aim of this study was to explore the underlying attitudes, barriers and facilitators to immunisation in east African communities in two states of Australia: New South Wales and Victoria.MethodsA qualitative study involving 17 semi-structured, in-depth interviews were undertaken with East African refugees and migrants living in two states of Australia: New South Wales and Victoria. These refugees and migrants were from four key East African countries: Kenya, Somalia, Ethiopia and South Sudan. Thematic analysis was undertaken to analyse and interpret the results.ResultsLanguage barriers, low risk perception and a lack of education were the key barriers identified by participants. Facilitators mentioned included the development of resources in participants’ languages and the implementation of reminder systems consistently across all GP practices. There was also a unanimous agreement amongst participants that community organisations need to play a greater role in the dissemination of information about immunisation.ConclusionsFurther research needs to be undertaken with regards to how education about immunisation is delivered and disseminated to refugee and migrant communities. Current findings also support the need to improve the health literacy of refugees and migrants by providing culturally and linguistically appropriate resources in participants’ respective languages.     

An innovative model of health care delivery: the care management program of the University of Iowa

The Indigent Patient Care Program (legislatively enacted in 1915) provides comprehensive health care to indigent Iowans without health insurance. The University of Iowa Hospitals and Clinics, a leading academic medical center, was designated as the health care provider for these medically and socially complex patients. The Care Management Program of the University of Iowa (CMPUI) is an innovative care delivery model responsible for total health management of patients enrolled in the indigent program. The CMPUI is a solution to preserve the tripartite missions of an academic medical center while ensuring the preservation of the historic Indigent Patient Care Program in Iowa.     

Costs of,and reimbursement for,vaccines: A case study at the Board of Health Refugee Services in DeKalb county,Georgia

Background

Approximately 70,000 refugees are resettled to the United States each year. Providing vaccination to arriving refugees is important to both reduce the health-related barriers to successful resettlement, and protect the health of communities where refugees resettle. It is crucial to understand the process and resources expended at the state/local and federal government levels to provide vaccinations to refugees resettling to the United States.

Objectives

We estimated costs associated with delivering vaccines to refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic).

Methods

Vaccination costs were estimated from two perspectives: the federal government and the DeKalb clinic. Data were collected at the DeKalb clinic regarding resources used for vaccination: staff numbers and roles; type and number of vaccine doses administered; and number of patients. Clinic costs included labor and facility-related overhead. The federal government incurred costs for vaccine purchases and reimbursements for vaccine administration.

Results

The DeKalb clinic average cost to administer the first dose of vaccine was $12.70, which is lower than Georgia Medicaid reimbursement ($14.81), but higher than the State of Georgia Refugee Health Program reimbursement ($8.00). Federal government incurred per-dose costs for vaccine products and administrative reimbursement were $42.45 (adults) and $46.74 (children).

Conclusions

The total costs to the DeKalb clinic for administering vaccines to refugees are covered, but with little surplus. Because the DeKalb clinic ‘breaks even,’ it is likely they will continue to vaccinate refugees as recommended by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices.     

Assessing the availability and accessibility of emergency contraceptive pills in Uganda: A multi-methods study with Congolese refugees

ObjectivesWe aimed to document the availability and explore the accessibility of emergency contraceptive pills for Congolese refugees living in both camp and urban settings in Uganda.MethodsIn 2017, we conducted a multi-methods assessment in both the Nakivale Refugee Settlement and Uganda’s capital of Kampala. Our study included a review of the published literature and institutional reports and statistics, 11 key informant interviews, 4 focus group discussions (FGDs) with married (N = 16) and unmarried (N = 20) Congolese women, and 21 in-person in-depth interviews with refugee women. We analyzed these data for content and themes using deductive and inductive techniques and triangulated our findings.ResultsOur findings show that the availability of emergency contraception in the Nakivale Refugee Settlement is inconsistent and theft of product by health center personnel is a significant problem. Congolese women living in Kampala reported that the cost of emergency contraceptive pills is prohibitive. Most of our refugee participants living in both settings lacked accurate knowledge about post-coital contraception and several reported using a range of other drugs to prevent pregnancy after sex.ConclusionEmergency contraception has long been incorporated into the standards of care for sexual and reproductive health in humanitarian settings. However, results from our study indicate that Congolese women face a range of challenges accessing emergency contraception in Uganda. Strengthening supply chain management, examining and addressing the dynamics underlying product theft, and increasing awareness of effective post-coital methods are priorities for expanding reliable access.ImplicationsInconsistent availability and lack of accessibility of emergency contraception has significant implications for refugee and displaced populations. Supporting efforts to ensure that humanitarian stakeholders in Uganda are adhering to global standards of care is critical.