Refugee Resettlement & Refugee Healthcare 101

Liz Andes: World Relief & Seattle Children’s Hospital

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS), under grant #T72MC00007/University of Washington Pediatric Pulmonary Center/PI: Redding, for total grant amount of $1,718,642. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

© Liz Andes 2017

Learning Objectives

1. Define a refugee

2. Increase understanding of what a resettlement agency is and what services

it is required to provide

3. Name two resources or tools that could improve your practice with refugee

patients

© Liz Andes 2017

Presentation Overview

-How are resettlement sites chosen?

-Role of the resettlement agency /services & benefits provided to refugees

-Overseas healthcare pre-arrival

-Department of Health Initial Health Screening (required for all refugees)

-Taking care of refugees in primary care

Definition - ref·u·gee : /ˌrefyo ͝oˈjē/

“Owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country.”

UNHCR, Article 1, The 1951 Convention Relating to the Status of Refugees

Source: UNHCR

A Refugee’s Pathway to the US

P1 Referrals

UNHCR, NGOs

US Embassy

P2 ReferralsSpecial Designated Groups

P3AORs, Family Reunification

VISA 92/93

USCIS

I-730s

Rec

eive

d b

y O

vers

eas

Pro

cess

ing

Enti

ty

(OP

E)

Du

plic

ate

Ch

eck

Cre

atio

n o

f fi

le a

nd

cas

e n

um

ber

Inte

rvie

w d

ate

sch

edu

led

Pre-Screening Interview

Verification of referral

Creation of case composition

Screen off non-qualified applicants (fraud, age, relationship)

Record basic bio info

Request security checks

Form Filling Interview

Record family trees:

-Names and birthdays

-Location of Birth

-Current Location

-Marital Status, # of Marriages, Type of Marriage

Cross-referenced info

Preparation of forms for CIS officer

Case Work Interview

Verification of all information during form fill

Write persecution story:

-Why had to leave COO (who, what, where, when, why)

-How & where did they flee

-Faced persecution since?

-Ever returned to COO?

-Can return today? Why or why not?

Compare story with referral and note discrepancies.

Cultural Orientation

Few hours to 3 days

Medical Checks (IOM)

Ok or treatment

Security Checks

Cleared or Pending

Cleared Security

Schedule Flight

Transit Center

Depart to US

ARRIVE!

USCIS Interview

Approve

Deny

Request Re-Interview

Appeal Denial

Courtesy Liz Andes

© Liz Andes 2017

Resettlement Agencies

Resettlement Agencies in Washington State by size:

1. World Relief 2. International Rescue Committee3. Lutheran Community Services4. Jewish Family Services5. Episcopal Migration Ministries

World Relief Affiliate Network

Placement Considerations

© Liz Andes 2017

Populations Arriving to Washington 10/1/2016-1/31/2017

Also: Belarus, Bhutan, China, Colombia, Ethiopia, Nepal, Philippines, Senegal, Sudan, Uzbekistan, & Vietnam

*Afghanistan & Iraq includes refugees and Special Immigrant Visa holders (SIVs)

Source: U.S. Department of State, Bureau of Population, Refugees, and Migration

© Liz Andes 2017

The Reception & Placement Program: 30-90 days

Goal: To help refugees achieve self-sufficiency; cover basic household expenses, navigate systems, and manage daily tasks.

Core Services

Arrival Services

Housing, Furniture, Clothing, Food

Home Visits

Distribution of resettlement funds

Registration with local government agencies to receive benefits

Selective Service Registration

Refugee Health Screening

Access to health services

School registration and English classes

Employment services referral

Cultural orientation

Casework Services; generally 30-90 days

© Liz Andes 2017

Healthcare Pre-Arrival

● Varies widely!● Rural vs. urban● Refugee camps or cities● Health literacy● War & trauma

© Liz Andes 2017

Overseas Conditions

Refugees face many public health challenges while fleeing and in refugee camps, including:

● Malnutrition● Continued violence, sexual assault● Lack of access to water

© Liz Andes 2017

Spotlight: Water Scarcity in Jordan2014 Mercy Corps Report:

Tapped Out: Water Scarcity & Refugee Pressures in Jordan

-In refugee-affected areas of the country, water shortages have hit emergency levels.

-In refugee camps, there is not enough water for basic health & hygiene

-In refugee-affected areas only 35% of population has access to a sewage network

-Zaatari refugee camp: many refugees have dug latrines next to their tents

© Liz Andes 2017

Overseas Conditions

-Refugees living in close conditions in camps; spread of communicable diseases

-Availability of medications for chronic illnesses are not always available

-Study found children living in refugee camps appeared to be at higher risk of asthma than children living in neighboring villages or cities (El-Sharif et al, 2002)

© Liz Andes 2017

Overseas Medical Screening

-Medical history, physical exam, mental status exam, syphilis testing, TB testing with chest x-ray, immunizations (some)

Goal: Identify Class A and Class B conditions

Class A: Physical or mental disorder that renders person ineligible for admission or adjustment of status (can get a waiver)

Class B: Significant health problems affecting ability to care for oneself, attend school or work, or require extensive treatment

Source: https://www.cdc.gov/immigrantrefugeehealth/exams/medical-examination-faqs.html#5

© Liz Andes 2017

Initial Health Screening Post-Arrival

-Intended to take place within first 30 days after arrival and before first visit with PCP

-May take up to 90 days if refugee moves from original resettlement state/county, no shows for several appointments, or refugee arrival volume is high

-Must be conducted by a qualified and licensed healthcare provider

King County: King County Public Health Refugee Screening Program

Pierce County: Tacoma-Pierce County Public Health Department

© Liz Andes 2017

Initial Health Screening

Initial Health Screening includes:

● Follow-up to overseas assessment/medical history review● Referral for mental health or specialty care● Triage of acute health issues including dental, nutritional,

hypertension, and lack of medication (refugee has run out)● Documentation of all previous immunizations and

administration of vaccines needed to comply with requirements for Green Card application

© Liz Andes 2017

Initial Health Screening

Screening for infectious diseases

● TB● Hep A, B, & C● HIV● Varicella

Lead screening

Emotional distress screening

Basic vision and hearing screening

Initial Health Screening(within 30 days, if possible)

PCP visit shortly after Initial Health Screening

Health screening results are sent to PCP and are available on WAIIS

© Liz Andes 2017

Primary Care Providers: First Visit

For up to date guidelines and best practices for primary care physicians, visit EthnoMed:

https://ethnomed.org/clinical/refugee-health/new-arrival-guidelines

Includes information about: labs, immunizations, mental health, women’s health, lead testing, & TB treatment

*Note: this document is specifically for patients in King County but will be helpful for all primary care physicians

© Liz Andes 2017

Healthcare Challenges for Newly Arrived Refugees

•The idea of primary care and preventive medicine is unfamiliar

•Multiple locations of care: public health, primary care, mental health, specialty care can be confusing

•Potential exposure to violence, warfare, internment and torture

•Mental health issues are prevalent and underdiagnosed

•Family integrity and social adjustment often trump medical concerns

•Language & cultural barriers

•Poor medical systems in country of origin can burden refugees with undiagnosed or poorly controlled chronic medical conditions Adapted from “Challenges Faced by Refugees and Their Health Care Providers” by Dr. Carey Jackson

& Shoshana Alenikoff’s “Refugee Health for Primary Care”

© Liz Andes 2017

Special Considerations for Refugee CareLanguage:

Even when interpreters are used, some languages do not have direct terminology for western

illnesses

Examples:

-Mien language has no word for mental illness

-Iranian women seeking alleviation of stress and anxiety from living conditions called it “heart

distress” and American doctors evaluated organic heart conditions

Adapted from Dr. Shoshana Alenikoff

© Liz Andes 2017

Special Considerations for Refugee CareCulture:

-May have cultural preferences about provider or interpreter gender

-May have cultural or religious practices that are inconsistent with US medical practices

Examples: Diabetes care during Ramadan, refusal of vaccinations

Transportation:

-Newly arrived refugees will primarily be using public transportation, though they may be eligible for Medicaid transportation services through Hopelink or Paratransit

Adapted from Dr. Shoshana Alenikoff

Pediatrics

© Liz Andes 2017

Pediatrics: Keep in Mind

- Refugee children are 5x more likely to have been out of school; some have never had formal education (United Nations High Commissioner for Refugees, 2016)

-November 2016 study of 982 refugee children in Washington showed nearly half suffered from malnutrition--either undernutrition or overnutrition (Dawson-Hahn et al, 2016)

-Save the Children 2017 report on Syrian refugee children:

-Many children are in a state of “toxic stress”

-Effects are: Bedwetting, self-harm, suicide attempts, aggressive/withdrawn behavior

© Liz Andes 2017

Mental Health

Refugees 10x more likely to suffer from PTSD than the general population (Fazel, Wheeler, & Danesh, 2005)

There is no such thing as Post Traumatic Stress Disorder for refugees -- the situations that brought them here are often still continuing!

Safety of family members

Guilt about leaving

© Liz Andes 2017

Mental Health

Assess signs/symptoms of depression, anxiety, PTSD, psychosis

● Screen for trauma; Suggested tool: Refugee Health Screener (RHS-15)

● Refer appropriately. Get to know your local mental health providers, especially those

who specialize in trauma-informed care.

CDC Recommendation:

“Were you ever a victim of violence in your former country?”

If yes, “Would you like to describe what happened to you?”

© Liz Andes 2017

Practical Tips for Mental Health ReferralsDiscuss symptoms

“I’m worried that you haven’t been sleeping very well and that your son says you cry all the time” NOT “You sound depressed.”

Normalize

“Lots of people who have been through what you went through have these symptoms.”

Offer support

“Sometimes people need extra support to help them through a difficult time.”

Give control and power

“You can go in and see if their services are right for you and meet the staff. If it’s not right for you, that’s okay.”

Source: Pathways to Wellness

© Liz Andes 2017

Health Issues: IraqisCDC’s priority health conditions for Iraqi refugees:

-Diabetes mellitus

-Hypertension

-Malnutrition

Other considerations:

- Not familiar with preventive medicine- May be dissatisfied with quality of care if no tangible treatment or prescription is provided- Many report confusion about when to visit primary care and when to seek emergent care

Source: Centers for Disease Prevention and Control Iraqi Refugee Health Profile

CDC creates Refugee Health Profiles which can

be found online

© Liz Andes 2017

Health Issues: Ukrainians

-Hypertension

-Arthritis

-Cognitive and developmental delays in children

-Cancer

Current caseload from Ukraine includes a high percentage of elderly individuals.

© Liz Andes 2017

Health Issues: Afghans

-Genetic disorders related to marriage between relatives

-Higher lead levels

-Dental problems

-Most Afghans currently arriving are young families; almost all women prefer a midwife to an OB

Photo courtesy Buzzfeed

© Liz Andes 2017

Healthcare Enrollment for Refugees

-All refugees are enrolled in Medicaid initially and receive the same benefits and access to the ACA as American citizens

-Refugees are approved for insurance within a few days of arrival, and coverage back dates to the 1st of the month

-Coverage continues based on income

© Liz Andes 2017

Tips for Providers

● Check with the resettlement agency: Does patient still have a caseworker?

● Resettlement staff can refer individuals who live in King County to the Refugee Health Promotion Project, which may be able to provide additional support, for up to 5 years post-arrival

© Liz Andes 2017

Resources

EthnoMed: Information about cultural beliefs, medical issues, and other related issues pertinent to the healthcare of recent immigrants

Also, Seattle & King County New Arrival Guidelines for Primary Care

The Refugee Health Promotion Project: Extended medical case management for refugees in King County run through Lutheran Community Services Northwest

Washington State Department of Health Refugee Program: Guidelines, additional information about screening, sign up for weekly emails

© Liz Andes 2017

ReferencesAlenikoff, S. 2016. “Refugee health for primary care.”

Dawson-Hahn, E., Pak-Gorstein, S., Hoopes, A., & Matheson, J. (2016). The Nutritional Health of Young Refugee Children Resettling in Washington State. Migration Policy Institute.

El-Sharif, N., Abdeen, Z., Qasrawi, R., Moens, G., & Nemery, B. (2002). Asthma prevalence in children living in villages, cities, and refugee camps in Palestine. European Respiratory Journal. 19 (6).

Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. The Lancet. 365 (9467).

Jackson, C. “Challenges faced by refugees and their health care provider.”

Mercy Corps. 2014. Tapped Out: Water Scarcity and Refugee Pressures in Jordan.

Pathways to Wellness. (2013). Creating Pathways for Refugee Survivors to Heal.

Save the Children. 2017. Invisible Wounds: The impact of six years of war on the mental health of Syria’s children.

Terasaki, G., Ahrenholz, N., & Haider, M. (2015). Care of Adult Refugees with Chronic Conditions. Med Clin N Am 99 1039-1058

© Liz Andes 2017

References, continuedUnited Nations High Commissioner for Refugees. (1951). The 1951 Convention Relating to the Status of Refugees.

United Nations High Commissioner for Refugees (2016). Missing Out: Refugee Education in Crisis. U.S. Department of Health and Human Services Centers for Disease Control and Prevention. (2014) Iraqi Refugee Health Profile. Retrieved from

https://www.cdc.gov/immigrantrefugeehealth/pdf/iraqi-refugee-health-profile.pdf

U.S. Department of Health and Human Services Centers for Disease Control and Prevention (2015). Guidelines for Mental Health Screening During the Domestic Medical Examination for Newly Arrived Refugees. Retrieved from

https://www.cdc.gov/immigrantrefugeehealth/pdf/mental-health-screening-guidelines.pdf

US Department of State, Bureau of Population Refugees & Migration. (2017). Refugee Arrivals by State & Nationality [data file]. Retrieved from http://www.wrapsnet.org/admissions-and-arrivals/

US Department of State, Bureau of Population Refugees & Migration. (2017). Cumulative Arrivals by State for Refugee and SIV - Afghan [data file]. Retrieved from http://www.wrapsnet.org/admissions-and-arrivals/

US Department of State, Bureau of Population Refugees & Migration. (2017). Cumulative Arrivals by State for Refugee and SIV - Iraqi [data file]. Retrieved from http://www.wrapsnet.org/admissions-and-arrivals/

Frank’s story courtesy of: Terasaki, G., Ahrenholz, N., & Haider, M. (2015). Care of Adult Refugees with Chronic Conditions. Med Clin N Am 99 1039-1058

Photos courtesy of: World Relief Seattle