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CANADA CARES: A PA’s Guide to Refugee Health Sarah Flanagan, CCPA B.A.Sc., M.A., B.Sc.PA. Sanctuary Refugee Health Centre Kitchener, ON, Canada [email protected]
CANADA CARES: A PA’s Guide
to Refugee Health
Sarah Flanagan, CCPA
B.A.Sc., M.A., B.Sc.PA.
Sanctuary Refugee Health Centre
Kitchener, ON, Canada
SRHC: Who Are We? Interdisciplinary primary care clinic
Provide medical & social support to refugees in KW & surrounding areas
Healthcare Providers: ◦ Dr. Michael C. Stephenson, MD, CCFP ◦ Sarah Flanagan, CCPA ◦ Kendra Weerheim, NP ◦ Kim Habermehl, RPN ◦ Robyn Stevens, RN ◦ Joanna Wu, RN
AND… Asmaa Cober, MSW
Settlement Workers
Translation Services
Psychology
Nutrition Counselling
Residents & Students
Community Allies: ◦ Reception House Waterloo Region
◦ CFFM Refugee Clinic ◦ Lang’s Community Health Centre
◦ Woolwich Community Health Centre
◦ Mennonite Coalition for Refugee Support
◦ Kitchener Waterloo Multicultural Centre
◦ YMCA Immigrant Services ◦ Waterloo-Wellington LHIN
PLUS: Volunteers! Administrative ◦ Front desk ◦ Follow up care coordination ◦ Scanning / charting ◦ Referrals ◦ Callbacks ◦ Translation ◦ Community awareness ◦ Cleaning / Decorating / Organizing
Healthcare providers ◦ Dr. McCuaig, OB/GYN ◦ Dr. El-Assar, MD, OB ◦ Psychologists ◦ Residents & Students
Sanctuary Refugee Health Centre: Who Are We?
Video Link:
http://kitchener.ctvnews.ca/remarkable-growth-for-kitchener-clinic-focused-on-refugee-health-1.3237383
Sanctuary Refugee Health Centre Our Patient Population: ◦Mostly young, physiologically healthy families ◦Very few cases of HTN, DMII ◦Physical trauma (GSWs, shrapnel, field amputations, TBIs) ◦Psychological trauma (imprisonment, torture, PSTD) ◦Prenatal care, pediatric care ◦Nationalities: Anywhere! ◦ Syria, Somalia, Iraq, Afghanistan, Burma, DRC, South Sudan, Sierra Leone,
Colombia, Venezuela, Mexico, Turkey, Côte D’Ivoire ◦ Languages: Arabic, Somali, Spanish, French, Tigrinya, Rohingya, Swahili,
Chin, Kurdish
Audience Input Experience with refugee patients? On a regular basis? Weekly basis? Daily basis?
Please interject with questions, concerns, and your own experiences at any time.
What is a Refugee? “An individual with a well founded fear of persecution on
the basis of race, religion, nationality, membership of a particular social group or political opinion, and is outside
the country of his or her nationality and unable to avail him or herself for the protection of that country.”
Refugee vs. Immigrant Immigrant: An individual who chooses to come to a new country.
Refugee: An individual who is forced to leave their home country. ◦ Consider: Implications of “The Grateful Refugee” Stereotype ◦ Most refugee arrivals were not able to choose country of resettlement ◦ Most did not ever wish to leave their home country ◦ Many maintain a desire to return, if able, to home country or rejoin family elsewhere
Types of Refugees Government Assistant Refugee (GAR): A refugee as declared by the United Nations and resettled to Canada by our government.
Privately Sponsored Refugee (PSR): A refugee who is given status by the United Nations and resettled by a group of individuals or an organization in Canada.
Refugee Claimant: An individual who has come to Canada to ask for protection whilst inside our borders.
“Others” Inland Claimants No health coverage pre-claim
Sponsored family members May have no coverage (e.g. NO OHIP for 3 months as Permanent
Residents)**
Undocumented No coverage
Victims of Trafficking Eligible for IFH, may have no coverage
Refugee Healthcare Coverage in Canada Federal Jurisdiction
Interim Federal Health (IFH) Program
Subsequent transition to provincial / territorial coverage (i.e. OHIP / ODB)
Interim Federal Health (IFH) Program Designed to offer national standardization of healthcare services, based on average provincial/territorial coverage for vulnerable individuals (i.e. ODB for OW / ODSP)
Covers: Medical visits, hospital care, laboratory investigations, drug coverage equivalent to provincial / territorial low-income plans (+ a few goodies!)
Vision care: Assessment + glasses
Dental care: VERY limited. Emergency care only.
Home care & long-term care
Physiotherapy: 10 sessions / calendar year
Hearing aids
Diabetic supplies, incontinence supplies, oxygen equipment
Prosthetics / orthopedic / mobility devices
Psychological assessment + 10 follow up sessions
Translation for first major assessment (GARs, PSRs only)
Immigration Medical Exam (Refugee Claimants only)
• Register to become an IFH provider:
http://www.cic.gc.ca/english/refugees/outside/arriving-healthcare/practitioners.asp
• Registration Form: https://docs.medaviebc.ca/providers/forms/providerifhpregistrationformtermsandconditions.pdf
• Interim Federal Health Program - Information Handbook for Healthcare Professionals: https://docs.medaviebc.ca/providers/guides_info/IFHP-Information-Handbook-for-Health-care-Professionals-April-1-2016.pdf
• Billing is very similar to provincial / territorial systems, but uses ICD-based billing codes
Interim Federal Health (IFH) Program
Government Assisted Refugees (GARs): Eligible for IFH and provincial/territorial coverage (i.e. OHIP) upon arrival (allow 72hrs)
Eligible for one Post-Arrival Health Assessment per patient
12-month financial support from Federal Government
Must repay travel loan from government *Unless* WE help apply for waiver
Privately Sponsored Refugees (PSRs) IFH coverage on arrival
May have to wait for provincial/territorial coverage (i.e. OHIP = 3months)
Flexible 12-month financial support from sponsors
Most VARIABLE experience
Refugee Claimants “Temporary” status
IFH once claim processed
Once approved, they lose IFH but gain provincial/territorial coverage
May qualify for provincial/territorial social assistance / disability supports in addition
Must complete Immigration Medical Exam (IME)
New Patient Intake Consider: What might be different, and what might be the same, in a refugee health clinic versus general Canadian population?
1st: Meet & Greet ◦ How do your patients come to you?
◦ Immigration Medical Examiners
◦ Local clinics for Post-Arrival
Health Assessments
◦ Triage at Hotels ◦ Word of Mouth
◦ Challenges in a Meet & Greet:
◦ Practitioner / patient relationship
◦ LANGUAGE! ◦ Cultural competency
◦ Location / Transportation – not always a choice!
New Patient Intake Explaining healthcare system navigation:
Appointments
Prescriptions
Medication Education - especially antibiotics
Wait times for specialty consults & procedures
When to seek care; where to seek care
Role of a primary care provider
Routine screening guidelines, preventative medicine
Patient History Past Medical History Language / Terminology? Medical documents? Immunizations?
Allergies
Medications Tylenol in Arabic?
Surgical history
Family history
Social history
Hospitalizations
Screening / Interventions Example: Mammograms & PAPs
cross-culturally
What Else for Refugee History? Country of Origin
Transition country(s)
Mode of arrival
Sponsorship type
Family situation – Who is here with them? Whom is elsewhere?
Dietary restrictions (Halal? Lactose? Vegetarian? Religious fasting?)
What doesn’t come up? INJURIES / SHRAPNEL / WARZONE EXPOSURES
◦Rima’s(*) Story: ◦ 32-year-old Syrian refugee
◦ 10-year-old son, 7-year-old daughter
◦ Both born in Syria
◦ SVD, uncomplicated pregnancy and deliveries
◦ Exclusively breastfed
◦ Met all developmental milestones
◦ 5 years ago, 5m pregnant, witnessed bombing of home, several relatives died
◦ Miscarriage at 5.5m GA, heavy bleeding, no medical interventions while fleeing Syria
◦ Refugee camp in Lebanon x3 years – 2 early GA miscarriages
◦ Arrived in Canada 1y ago, almost
immediately became pregnant ◦ Delivered low birth weight baby girl at 36
weeks GA ◦ Struggling with breastfeeding; cannot
nurse on right breast ◦ WHAT DO YOU DO?
◦ Door handle question: “Is it the bullet in
my chest?”
What do you do? Communication is KEY! ◦ RIO Network – 416-324-2731 ◦ Local Multicultural Centres ◦ Local Settlement Offices ◦ Community Volunteers
ASK: Injuries, Trauma, Shrapnel ◦ Explosions, stabbings, GSWs – these are shockingly normal in some regions and may
never have received medical attention, therefore will not be disclosed unless asked!
INSPECT: Complete physical examination ◦ Allow patients time, a safe space to disclose ◦ This may take multiple visits ◦ Disclosure may never happen – do NOT push too hard ◦ DO document findings, explained or unexplained
Physical Examination Considerations Draping
“Others” in the room - translators, childcare, etc.
Cross-cultural gender norms
Female Genital Mutilation / Circumcision http://www.who.int/reproductivehealth/topics/fgm/overview/en/
Investigations Routine New Patient labs? ◦ CBC, Random glucose, A1c, Lipids,
LFTs, eGFR, Creatinine, TSH, Ferritin, B12
◦ Urinalysis, ?Pregnancy, Chlamydia, Gonorrhea
◦ Vaccinations: Rubella, Varicella ◦ All new-comers: Hep Bs Ag, Hep C,
Syphilis, HIV ◦ Syrian: G6PD, Thalassemia,
hemochromatosis
Antenatal labs / investigations / history for new arrivals? ◦ Parvovirus ◦ CMV ◦ ?Malaria ◦ FGM
Normal “Abnormal” Results / Findings • Iron deficiency, B12 deficiency, nutritional deficiencies
• Extreme dental decay
• Traumatic injuries: amputations, head injuries, GSWs, shrapnel
• Tuberculosis
• Hepatitis B
• Thalassemia (& other hematological disorder - Sickle Cell, G6PD, hemochromatosis…)
• Neutropenia
• Consanguinity
• FGM
• Parasitic infections (schistosomiasis, strongyloides, Giardia, Bastocystis hominis)
Mental Health / PTSD Extremely significant aspect of competent healthcare for refugees
Do not address at intake visit!! (Unless patient discloses
independently)
Coordinate with local mental health professionals & organizations
Focus on impact on FUNCTION
Recognize that most refugees will have mental health needs Migration trauma Post-arrival shock 6-12m low First winter 12m transition of support Citizenship stressors Traumas / Triggers from home You must be aware of international news!
Refugee Mental Health Mental Health symptoms are (essentially) universal ◦ Sleep disruption ◦ Homesickness ◦ Temporary low mood – specific triggers
◦ Survivor’s guilt ◦ Anxiety – resettlement, frustrated potential, separation from loved ones
Timing ◦ Highest risk: ◦ Immediately after arrival (resettlement / culture shock)
◦ 1 year (transition of support services)
◦ Secondary trauma (i.e. car accidents)
Highest Risk Groups • Torture survivors
• Victims of sexual violence
• Precarious immigration status
• Separation from immediate family members
• Previously high socioeconomic status
• Poor language skills
• Pre-existing disorders (ADHD, personality disorders, schizophrenia)
How to Manage Mental Health Understand the cross-cultural implications of mental health presentation and management ◦ Culture can influence responses to stress / trauma ◦ Symptoms can be presented in culturally appropriate ways
Avoid: ◦ Dismissing: “We don’t believe that in Canada” ◦ Overgeneralizing: “All Middle Eastern people believe ---, therefore you must
too.” ◦ Pathologizing: “Butterflies in the stomach? That sounds delusional!”
Do not over- NOR under-estimate the impact of psychological trauma on physiological symptoms
• Consider the Case: ◦Momena(*), 40-year-old
female, rural Sierra Leone ◦ Significant psychological
trauma ◦Arrival in Canada as PSR late
2016 ◦On-going extreme abdominal
and pelvic pain, plus chronic joint pain
◦ First GP connection failed – patient felt as though her symptoms were trivialized, pathologized as part of her past trauma, not physiological
◦ Reported history of intermittent unilateral large joint edema, pain
◦ Abdominal ultrasound WNL
◦ What do you do?
◦ Refer to OB/GYN – multiple adhesions form previous abdominal / pelvis trauma – hysterectomy
◦ R/o inflammatory / autoimmune disease – POSITIVE FOR SLE
How to Manage Mental Health Try to understand the individual – value their own context and experience
Prepare and educate yourself If you are asking about mental health, you must be prepared to deal with it!
Dissociation and psychotic symptoms are poor prognostic indicators – support and refer early
Understand that a patient may never disclose specific traumas
Addressing determinants of health (housing, food, security, employment, education) is evidence based mental health care
Challenges in Refugee Healthcare • Patients all navigating a new healthcare system
• Appointments?
• Wait times?
• Access to services?
• LANGUAGE
• Case management
• Referrals / specialists
• Volunteer-run staff
• Creating safe space
• and of course… FUNDING!
All of the Extras Use interpreters to model trusting relationships in the context of trauma
Ask for community help ◦ IMGs – Utilize individuals from similar backgrounds to aid patients in
navigating the Canadian healthcare system ◦ They get references and experience too!
Do not underestimate the importance of paperwork – medical or otherwise! ◦ Excellent use of a PA in refugee health context
Know your local resources and community allies
Helpful Links & Resources • Canadian Counsel for Refugees: http://ccrweb.ca
• Immigration and Refugee Board of Canada: http://www.irb-cisr.gc.ca
• Interim Federal Health Program: Summary of Coverage - http://www.cic.gc.ca/english/refugees/outside/summary-ifhp.asp
• Canadian Medical Association Journal - Refugee Health: http://www.cmaj.ca/site/misc/refugee-health.xhtml
• Canadian Paediatric Society - Immigrant and Refugee Health: https://www.cps.ca/en/issues-questions/immigrant-and-refugee-health
• www.RefugeeHealth.ca
• www.settlement.org (Ontario)
• Sanctuary Refugee Health Centre: www.sanctuaryrefugee.ca
Questions? Comments? Concerns?
https://www.therecord.com/news-story/7547360--the-best-doctor-i-ever-met-kitchener-refugee-centre-gets-a-new-home/
