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Refugee Resettlement &
Refugee Healthcare 101Liz Andes, MSW, LSWAIC
Pulmonary Social Worker
Seattle Children’s Hospital
April 8th, 2019
Who is a Refugee?A refugee is a person who "owing to a
well-founded fear of persecution 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
Refugee Asylee
Immigrant
Pop Quiz!
How many uprooted people are
there worldwide?
• 35 million
• 42 million
• 68 million
• 1 billion
Refugees - Triple Trauma Paradigm
Fleeing Encampment
or Exile
Resettlement
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
Re
ceiv
ed
by
Ove
rse
as P
roce
ssin
g En
tity
(O
PE)
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 Committee
3. Lutheran Community Services
4. Jewish Family Services
5. Episcopal Migration Ministries/
Refugee Resettlement Office
World Relief Affiliate Network
Placement Considerations
Ali: Somalia
© 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 & 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
Resettlement—A Life Crisis
90 Days of
Resettlement
Casework
© Liz Andes 2017
Healthcare Pre-Arrival
• Varies widely!
• Rural vs. urban
• Refugee camps or cities
• Health literacy
• War & trauma
© 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
treatmentSource: https://www.cdc.gov/immigrantrefugeehealth/exams/medical-examination-faqs.html#5
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
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 disease
and immunity
• TB
• Hep A, B, & C
• HIV
• Varicella
Lead screening
Emotional distress screening
Basic vision and hearing
screening
© Liz Andes 2017
Healthcare Challenges
•Preventive/Primary care
•Multiple locations of care
•Mental health issues are prevalent and underdiagnosed
•Social adjustment often trumps medical concerns
•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 Aleinikoff’s
“Refugee Health for Primary Care”
© Liz Andes 2017
Special Considerations: Language
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 Aleinikoff
© Liz Andes 2017
Special Considerations:Culture
-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
Pediatrics
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)
Setting the Stage for Discussing Mental Health
Discuss in SYMPTOMS not Diagnosis
NORMALIZE
Explain what MENTAL HEALTH MEANS in the U.S.
Give CONTROL and POWER
Explain who you are what is going to happen
Explain in detail about CONFIDENTIALITY
© Liz Andes 2017
Health Issues: Iraqis
CDC’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: Afghans
-Genetic conditions related to
marriage between relatives
-Higher lead levels
-Dental problems
-Most Afghans currently arriving
are young families; many
women prefer a midwife to an
OB
Photo courtesy Buzzfeed
© Liz Andes 2017
Healthcare Enrollment
-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
Case Example: Muthana
Doctor: How long have you been having seizures? Duration,
intensity, medications
Dietician: Is diet playing a factor in seizures? Food insecurity
in the home?
Social Worker: Adherence and problem-solving; integration
into new community, resource-brokering
© Liz Andes 2017
What We Missed: Trauma!
• Patient was a torture victim whose history of trauma was
contributing to seizure
© Liz Andes 2017
Cultural Competence & Cultural
Humility
• Cultural competence: Styles of communication, how to
interact with a doctor, what information to disclose to
people outside family, etc.
• Cultural humility: “the ability to maintain an interpersonal
stance that is other-oriented (or open to the other) in
relation to aspects of cultural identity that are most
important to the person” (Hook, 2013)Hook, J.N. (2013). Cultural Humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology.
© Liz Andes 2017
A flourishing system
• Basic knowledge + cultural humility +
curiosity
• Time
• Recognition of diversity within the label
• Cultural navigators with personal history
• Case management + mental health
Capstone Project
Situation: Lack of clinical
expertise outside King County
+ long wait times for initial
PCP visit
Flyer to clinics in
person (8)
Town Hall Seattle
Dr. Mary
Barinaga, UW
Idaho WWAMI
Refugee Health
Conference
Future training of
HealthPoint &
Harborview Int’l
Medicine
residents
PPC Website
Presentation to
Valley Family
Medicine
residents
Flyers by email
using
“insiders”(15)
Given to all
resettlement
agencies for
continued
connections
Distribution Plan
The New Arrivals Working Group
Examples of change:
• Hopelink rides for all refugees for 90 days
• Training providers to become Civil Surgeons
• Citizenship medical forms
Challenges to Change
• Job description (find a way to stay
connected)
• Time
• Varying interest of providers
• Concept of “equity” for patients
© 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
ReferencesAleinikoff, S. 2016. “Refugee health for primary care.”
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.”
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
United 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.
© Liz Andes 2017
References, continued
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/
Photos courtesy of: World Relief Seattle
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