nwm_care_planning_refugee_health by suiqizheng


									            WestBay Alliance
        Brimbank Melton PCP

   Care Planning
for Refugee Health
  An Evolving Model
         Care Planning
       and Refugee Health
• Refugee health care is complex and
• Its success is dependant upon an integral
  understanding of the ‘whole’ picture of
  what is going on in a refugee’s life.
• Refugee Care Planning must be done
  within the framework of the service
  coordination pathway.
• It must involve consideration of the other
  issues going on for the refugee.
         Background to
 Primary Care Partnership (PCP)
     Refugee Health Projects
• One-off statewide initiative to support the
  integration of newly arrived refugee entrants.
• Facilitated by Primary Health Branch of the
  Department of Human Services (DHS).
• Funds allocated to each of the 8 PCPs
  where Refugee Health Nurses (RHNs) are
• Projects complimented the
  RHN Initiative.
 Aim of the Refugee Projects
• To develop stronger, more integrated, and
  community-based, health and community
  services for refugees by:
  – Reducing duplicative practices.
  – Increasing understanding of referral and
    care pathways.
  – Improving service coordination and
    care planning.
  – Delivering integrated health
    promotion practice.
         This PCP Project

• A joint Refugee Health Project for the
•    2 Primary Care Partnerships (PCPs):

    • WestBay Alliance (PCP)
       – Wyndham
       – Hobsons Bay
       – Maribyrnong
    • Brimbank / Melton PCP
        Project Objectives
• To progress work on developing care
  pathways for refugees across a range
  of service providers.
• In partnership and cooperation with GP
  – Improve care coordination between GP
    practices and health providers.
  – Support new GPs willing to work with
           Objectives cont.
• To identify and link with other appropriate
  services such as Infectious Disease Units.
• To encourage the use of the Service
  Coordination Tool Template and the
  Statewide GP Referral Template.
• Identify and prioritise service gaps and
  workforce development needs.
• To identify opportunities for further
  funding / support.
 Steps involved in the Project
1. Established an advisory group with 2 key
   service providers – WRHC & ISIS
2. Held discussions with Refugee Service
   Providers in the 5 LGAs.
3. Mapped Current Care Pathway.
4. Documented Enablers and Barriers to
   Refugee’s access to and experiences
   with the health system.
         Discussions with
         Service Providers
• Western Region Health Centre
• AMES – Adult Multicultural Eduction Services
• Migrant Resource Centre
• GP Divisions – Western Melbourne and Westgate
• Royal Melbourne Hospital
• ISIS Deer Park
• Royal Children’s Hospital - Immigrant Clinic
• Victorian Foundation for Survivors
  of Torture
• Western Hospital
           Discussions with
        Service Providers cont.
•   Maribyrnong City Council
•   Brimbank City Council
•   Maribyrnong & Brimbank Family Services
•   Other Metropolitan PCPs
•   Melbourne City Mission
•   Royal Women’s Hospital
•   Dinka & Karen Refugee Representatives
•   New Hope Foundation
•   Local Churches
    Mapping Current Care
Pathway according to Service
   Coordination Principles
• The documentation of current care
  pathways occurred after discussions with
  many settlement and health service
• These pathways attempt to map how a
  refugee negotiates the settlement and
  health system, after they arrive in the
                                Current Care Pathway        DRAFT                         DRAFT                            DRAFT                                  DRAFT
                                                                                                                                                                                                                WestBay Alliance and Brimbank Melton PCPs
                                                                                                                                                                                                                              Refugee Health
                                                                                                                                                                                                                       Service Coordination Project

     CURRENT SETTLEMENT                                                                                                                         CURRENT CARE PATHWAY
                                                                                                                                                           FOR REFUGEE ACCESS
REFUGEE & SPECIAL HUMANITARIAN                                                                                                                            TO HEALTH SERVICES IN
       VISA HOLDERS IN                                                                                                                         Maribyrnong, Hobson's Bay & Wyndham,
                                                                                                                                                         Brimbank & Melton
             Maribyrnong, Hobson's Bay & Wyndham,
                       Brimbank & Melton

                  PRE-DEPARTURE                SETTLEMENT                                                                                                             ASSESSMENT
   VISA                                                                                    INITIAL            INITIAL NEEDS                                                                                                                              TREATMENT &
                                                SUPPORT                                                                                                                                                          CARE PLANNING
   TYPE              MEDICAL                                                              CONTACT            IDENTIFICATION                                                                                                                               FOLLOW-UP
                     SCREEN                                                                                                                        INITIAL                               FURTHER
                      (PDMS)                                                                                                                     ASSESSMENT                            ASSESSMENT
                                               DIAC inform Western
                                              Hospital (WH) Migrant
                                              Screening (TB Clinic)                                                                                 WH Migrant                                                        WH TB Clinic                         WH TB Clinic
                                                                                        Western Hospital
                                              of health undertaking                                                                               Screening Clinic                         WH Radiology
                                                                                        Migrant Screening
                                                     entrants                                                                                         Doctors
 200 & 204            PDMS arranged                                                      (TB Clinic) send
  Refugee             within 72 hrs prior                                               appointment letter
  Entrant                  to travel                                                        to entrant                                                                                                            WH Migrant Screening
                                                                                                                                                                                           Within Hospital                                                 RCH TB Clinic
                                              DIAC informs AMES of                                                                                                                                                   Clinic Doctors
                                                                                                                                                                                          or Health Centre
                                                 entrant's arrival
                                                                                                                    WH Migrant                                                          Radiology, Pathology,
                                                                                       AMES Case Worker           Screening Clinic                                                     Pharmacy, Immunology,                                               WH Infectious
                                                                                         (if aware of WH              Doctors                                                             Counselling etc.           WH Infectious
                                                                                      appointment) ensures                                                                                                           Disease Clinic
                      Entrant provided                                                   entrant attends
                                                  AMES informs
                        PDMS papers
                                             consortium agencies -
                      (including Red or
                                             Red Back, Brotherhood                                                                                                                           STD Clinic               WH Hepatitis                         WH Hepatitis
                    Yellow Alert or signed
                                              of St Laurence, VFST                                                                                                                           Melbourne                  Clinic                               Clinic
                     Health Undertaking)
                                                                                                                                                   WH Infectious
                                                                                                                                                   Disease Clinic

                                                                                            Hospital                                                                                                                 RMH Infectious                       RMH Infectious
                                                                                           Emergency                                                                                                                 Diseases Clinic                      Diseases Clinic
                                              AMES provides Case
                                              Worker within 24 hours                       Department                                              WH Hepatitis
                                               & Community Guide                           (Red Alert)                                               Clinic
                                              Support for 6 months
                                                                                                                                                                                            Maternal &              RCH Immigrant                            STD Clinic
                                                                                                                                                                                            Child Health            Screening Clinic                         Melbourne
                                                                                                                  Public or
                                                                           GAP                                     Private                              RMH
                                               AMES Case Worker                                                  Bulk-billing                        Infectious
                                                arranges medical            Some                                 GP Clinics                          Diseases
                                                                          refugees       Public or Private                                                                                                                                                  Maternal &
                                             attention for alert cases                                          (with refugee                          Clinic
                                                                           (202s)           Bulk-Billing                                                                                  Royal Women's                                                     Child Health
                                                 and later health                                                 interest)
                                                                           get lost         GP Clinics                                                                                       Hospital
                                                                           at this        with Refugee
                                                                            stage        Interest (Yellow
                                                                                          Alert or Health                                                                                                                                                 Royal Women's
                                                                                                                                                       RCH               Public or
                                               DIAC inform Western                         Assessment)                                                                                                                                                       Hospital
                                                                                                                                                     Immigrant            Private             Dentist
                                              Hospital (WH) Migrant
                                                                                                                                                  Screening Clinic      Bulk-billing
                                              Screening (TB Clinic)
                                                                                                                                                                        GP Clinics
                                              of health undertaking                                                                                                                                                                                           Dentist
                                                                                                                                                                       (with refugee
                                                                                                                                                                         interest)            Dietician
                                                                                                                                                                                                                                           Public or
                                                                                            Refugee                                                                                                                                         Private           Dietician
                                                                                             Health            Refugee Health                                                                                                             Bulk-billing
     202             PDMS difficult to
                                                   DIAC provides                          Nurse (RHN)               Nurse                        Public Laboratory                                                                        GP Clinics
   Special           arrange but Visa
                                                    AMES with                             where present        screens entrants                  Testing Centres                            Optometrist                                  (with refugee
Humanitarian        Medical Examination
                                                 proposer's details                                               for health                        (Radiology,                                                                            interest)        Optometrist
Entrant (SHP)           conducted
                                                                                                                 assessments                         Pathology,
                                                AMES provide case
                                                                                                                                                                                            Allied Health                                                   Allied Health
                                               worker, who contacts
                                                                                                                                                                                            (Physio, OT,                                                    (Physio, OT,
                                             proposer with checklist of
                                                                                                                                                                                            Podiatry etc)                                                   Podiatry etc)
                                              orientation information
                                                                                                                                  Community      Private Laboratory
                                                                                         VFST for Psych                             Health        Testing Centres
                                                                                           screening                             Nurse (CHN)         (Radiology,
                                                  AMES arranges                           assessment                            where no RHN          Pathology,                                                                                         Community Support
                                                   Brotherhood of                                                                  present          Immunology)                                                                                              Groups
                                                  St. Laurence for                                                                                                                        Medicare funded
                                                 furniture package                                                                                                                         Psychologist
                                                                                          VUT, WELS &                                                                                                                                                     Medicare funded
                                                                                         other schools,                                                                                                                                                    Psychologist
                                                                                      Churches & Charities
                                               AMES Case Worker                              pick up
                                              informs proposer how                      these refugees
                                                 to access health                                                                                                                              VFST                                                            VFST
                                                                                           over time
                                                   assessments                                                                                                                             (Psychological                                                  (Psychological
                                                                                         (up to 3 years)
                                                                                                                                                                                            Counselling)                                                    Counselling)

                                                                                                                                                                                                                WestBay Alliance and Brimbank Melton PCPs
                   DRAFT                                    DRAFT                         DRAFT                            DRAFT                                  DRAFT                                                       Refugee Health
                                                                                                                                                                                                                       Service Coordination Project
Barriers experienced by Refugees
   during Pathway Negotiation
• The complexities and duplication in the process.
• Misunderstanding about Pre-Departure Medical
  Screen results.
• Different allocations of support for different Visa
• Health system illiteracy and ignorance about
  health system negotiation
• ‘Falling through the cracks’ before establishing
  a connection with health system.
Barriers experienced by Refugee cont.
• Initial TB screening only conducted at Western
  Hospital for the whole state.
• Gaining access to an Interpreter when unable to
  speak or understand English.
• Waiting lists for appointments and services.
• High health demands due to years spent in
  refugee camps with poor diet, limited resources,
  and limited access to essential medical care.
• Public transport access and a different concept
  of time-keeping for appointments.
• Confusion and misunderstanding about
  tests / medication / therapy / follow-up.
Steps involved in the Project cont.
 •   5. Developed a Proposed Care Pathway, with
     incorporated enablers.
 • 6. Developed a Complexity Screen
 • 7. Presented results to service providers at a
     forum (up to 50 providers).
 8. Established a working group of selected service
     providers (18 members) to refine pathway and
     complexity screen.
 9. Developed a protocol to guide implementation.
 10. Provided feedback to larger group at a second
        Developed a new
     Proposed Care Pathway
• Based on Service Coordination principles.
• More efficient and unified.
• Facilitating health access that is more:
  – streamlined
  – structured
  – supportive of the newly arrived refugee.
• Uses ‘intake’ and ‘access’ roles or personnel to
  assist the refugee along the Care Pathway
  suited to the complexity of their situation
                                                                        Proposed Care Pathway
                                                                                                                                                                                                                                                                                                                                                                                                                                         WestBay Alliance and Brimbank Melton PCPs
                                                                                                                                          DRAFT                                   DRAFT                                  DRAFT                         DRAFT                                    DRAFT                                                                                                                                                  Refugee Health
                                                                                                                                                                                                                                                                                                                                                                                                                                                Service Coordination Project

Proposed Roles &
Responsibilities of                                                      PROPOSED SETTLEMENT PATHWAY                                                                                                                                                                            PROPOSED HEALTH CARE PATHWAY
Service Providers                                                                                                                                                                                                                                                                                             FOR REFUGEE ACCESS
in Health Care                                                                      REFUGEE & SPECIAL HUMANITARIAN                                                                                                                                                                                           TO HEALTH SERVICES IN
Pathway (new                                                                           PROGRAM VISA HOLDERS IN
responsibilities                                                                  Maribyrnong, Hobson's Bay & Wyndham, Brimbank & Melton
                                                                                                                                                                                                                                                                      Maribyrnong, Hobson's Bay & Wyndham, Brimbank & Melton
are in blue)
Department for Immigration and
                                                                                                                                                       SETTLEMENT                                                                                                                                                                    ASSESSMENT                                                                                                                             underlying
Citizenship (DIAC)                                                                                                                                                                                                                               INITIAL NEEDS                                                                                                                                                                    CARE                  TREATMENT &
* Ensures (where possible) that IOM                               DIAC INITIAL CONTACT                                                                  SUPPORT                                               INITIAL CONTACT                                                                                                                                                                                                                                               success
                                                                                                                                                                                                                                                IDENTIFICATION                                                                                                                                                                  PLANNING                 FOLLOW-UP
  (International Organisation for Migration)
  has carried out and forwarded PDMS
                                                                                                                                                                                                                                                                                                                                                                       FURTHER ASSESSMENT                                                                                   of Health
  (Pre-Departure Medical Screen) results
* Refers to AMES (Adult Multicultural                VISA                                                                                                                                                                                                                                                                                                                                                                                                                   Care
  Education Services) all Refugee and SHP
                                                     TYPE               PRE-DEPARTURE
  (Special Humanitarian Program) entrants
  who have been provided with Visas.
                                                                        MEDICAL SCREEN                                                                                                                                                                                                                                                                                               Active TB                                                                 Western      Pathway
                                                                                                                                                                                                                                                                              Health Underrtaking -                                                                                                                                                            Hospital
* Includes PDMS information in referral                                     (PDMS)                                                                                                                                                                                            WH Migrant Screening
                                                                                                                                                                                                                                                                                                                                                                                     Latent TB                                                                 TB Clinic    Implemen-
  to AMES                                                                                                                                                                   Red Alert -                                                                                         (Statewide TB Clinic
* Informs AMES of Health Undertaking                                                                                        Red Back                                         Hospital                                                                                         for Health Undertaking)                                                                                                                                                                       tation
  referrals to WH (Western Hospital)                                                                                    Airport transport &                                 Emergency                                                                                                                                                                                                 No TB
  Migrant Screening Clinic                                                                                              temporary housing                                      Dept
                                                                                                                                                                                                                                                                                                        WH Infectious
                                                                                                                                                                                                                                                                                                                                                                                  RCH TB Clinic
                                                                                                                                                                                                                                                                                                        Diseases Clinic                                                                                                                                        Specialist
AMES Case Coordinator                                                                                                                                                                                                                                                                                                                                                                                                                                           Medical
* Coordinates referrals to consortium                                                                                                                                      Yellow Alert -
  partners                                                                                                                                                                Public or Private                                                                                                                                                       Within Hospital
* Conducts holistic screen of entrant's                                                                                                                                     Bulk Billing                                                                                                                                                         or Health Centre                                         Specialist
                                                                                                                                      Brotherhood of                                                                                                                                                 WH Hepatitis Clinic
  needs                                                                   PDMS occurs within
                                                                                                                                       St. Laurence                        GP Clinic with                                                                                                                                                           Radiology,                                             Medical                                                          * Client
* Conducts Complexity Assessment                                          72 hrs. Can include                                                                                                                                                                                                                                                       Pathology,
                                                    200 & 204                pre-departure                                               Furniture             AMES       Refugee Interest                                                                                                                                                                                                                                                                                    Focussed &
  to determine health referral pathway                                                                                                                      Community                                                                                                                                                                               Pharmacy,                                                                                              Allied Health
* For high complexity cases:                     Refugee Entrant              results form,                                              package              Guide /                                                                                                                                                                              Immunology,                                                                                                                Empowering
                                                                                                                                                          Access Worker                                                                                                                                                                                                                                                                                      (Dentist,
  Coordinates referral to RHN /                                             health manifest &                                                              etc arranges                                                                                                                                                                          Counselling etc.
                                                                                                                                                                                                                                                                                                        RMH Infectious                                                                                                                                     Optometrist,
  CHN and follows-up RHN / CHN meeting                                     health undertaking                                                               transport-
                                                                                                                                                               ation                                                                                                                                    Diseases Clinic                                                                                                                                     Dietician,      * Informed
  with entrant and interpreter to complete                                                                                                                                                                                                                                                                                                                                                               Allied Health                                     Audiologist,
  initial health needs identification                                                                                                                                                                                                                                                                                                                                                                      (Dentist,                                                          Consent &
                                                                                                                                                                                                                                                                                                                                                                                                                                                           PT/OT etc)
  summary and referral to GP                                                                                                                                                                                               Refugee                                                                                                                                                                       Optometrist,                                                         Privacy
* For low complexity cases:                                                                                                                                                                                                 Health                                                                                                                                                                        Dietician,
                                                                                                                                                                                                 AMES                                                                                                   RCH Immigrant
  Coordinates referral to GP with Clinic                                                                                                                                                                                 Nurse (RHN)                                                                                                                                                                     Audiologist,
                                                                                                                                                                                              Community                                                                                                 Screening Clinic
  Nurse, providing appropriate entrant                                                                                                                                                                                      (where                                                                                                                                                                       PT/OT etc)                    Public /                             * Culturally
                                                                                                                                          Case Coordinator &                                     Guide /                   present)     Combined
  information. Clinic Nurse arranges initial                                                       DIAC                                                                                                                                                   AMES                                                                                                                                                                       Private GP                               Sensitive &
                                                                                                                                           Community Guide                      High             Access                                    initial
  assessemnt with interpreter and entrant                                                         informs               AMES                                                                                                                           Community                                                                                                                                                                     with RHN /
  and/or GP.                                                                                     AMES of               Settle-              for 200 & 204                    Complexity         Worker /                                  assess-
                                                                                                                                                                                                                                                         Guide /          Public or                                                                                                                                                                            Specialist     Respectful
                                                                                                                                               entrants                      200 & 204         Volunteer                                 ment with                                                                                                                              AMES                                               CHN and liaison
* Coordiates appropriate and                                                                      entrant               ment                                                                                                                              Access         Private Bulk                                                                                                                                                with AMES                 Women's
                                                                                                                                            (for 6 months)                   Cases and          Support                                  Refugee,                                                                                                                            Community
  corresponding Community Guide /                                                                arrivals or           Support                                                                                                                          Worker /            Billing                                                                                                                                                     Case                    Health      * Information
                                                                                                                                             & on request                    202 Cases          arranges                                  RHN or                                                                                                      Hospital                  Guide /
  Access Worker / Volunteer support                                                              proposer                                                                                                                                               Volunteer         GP Clinic                                                                                                                                                 Coordinator
* Communicates with GP and RHN / CHN                                                               details                                      for 202                     (on request)        appoint-                  Community       CHN &
                                                                                                                                                                                                                                                         Support             with                                                                    Specialist                 Access                    Specialist                                                          Provision &
                                                                                                                                                                                                ments &                  Health Nurse   Interpreter                                                                                                  or Public /               Worker /                                               decide on
  for input into Team Care Plan (Service                                                                                                                                                                                                                arranges          Refugee                 Public Laboratory Testing                                                                               Women's                                                             Sharing
                                                                                                                                                                                               transport-                   (CHN)                                                                                                                 Private GP with             Volunteer                                              Care Plan
  Coordination Plan)                                                                                                                                                                                                                                    appoint-           Interest                 Centres (Radiology,                                                                                    Health
                                                                                                                                                                                                  ation                   (where no                                                                                                                 RHN / CHN                  Support                                                   and
* Empowers and educates entrant in                                                                                                                                                                                                                      ments &                                    Pathology, Immunology)                                                                                                            Treatment
  involvement and management of their
                                                                                                                                                                                                                                                                                                                                                    coordinates                arranges                                                                    Community        * Partnership
                                                      202                                                                                                                                                                  available)                                                                                                                  further                 appoint-                                                                     Support
own                                                  Special                                                                                                                                                                                              ation
                                                                                                                                                                                                                                                                                                                                                   assessments                 ments &                                                                      Groups
  health care plan                                Humanitarian                                                                                                                                                                                                                                                                                                                transport-                                                                                      Refugee
                                                  (SHP) Entrant                                                                                                                                                                                                                                                                                                                  ation
                                                                         PDMS rare but Visa
Refugee Health Nurse (RHN) /                                                                                                                                                                                                                                                                                                                                                                              Specialist
                                                 Also Visas 201,         Medical Examination
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            * Collaboration
Community Health Nurse (CHN) /                    203, 866 are           conducted (including                                                                                                                                                                                                     Private Laboratory Testing
Clinic Nurse                                                                                                                                                                    Low                                                                                                                   Centres (Radiology,                                                                                  Health                                          Specialist         Between
                                                   eligible for           health undertaking)                                                                                                                                               Initial                                                                                                                                                                                                       Mental Health
* Conducts initial health needs                  some services                                                                                                               Complexity                                     Clinic                                                                 Pathology, Immunology)                                                                                                                                                     Agencies &
  identification with refugee and interpreter,                                                                                                                               200 & 204                                     Nurse @                                                                                                                                                                                                                                            Client
  and communicates with AMES Case                                                                                                                                            Cases and                                     GP Clinic
                                                                                                                                                                                                                                         Refugee &
  Coordinator regarding action and referrals                                                                                                                                 202 Cases                                      or GP
* Ensures appropriate referral and                                                                                               Foundation House                           (on request)                                                                                                                                                                                                                                                                                    * Shared
  entrant information is forwarded to                                                                                                                                                                                                                                                                                                                                                                    Foundation
                                                                                                                                 - Psych screening                                                                                                                                                                                                                                                                                                          Foundation        Responsibility
  GP (ideally as part of Refugee Health                                                                                                                                                                                                                                                                                                                                                                      House
                                                                                                                                    assessment                                                                                                                                                                                                                                                                                                                House
  Assessment or Service Coordination             447, 451, 695,                                                                                                                                                                                                                                                                                                                                           - Intensive
                                                 785, 786 & 070                                                                                                                                                                                                                                                                                                                                              Psych
  Tool Templates - SCTT)
                                                                                                                                                                                                                                                                                                                                                                                                                                                           Counselling)     * Strengths
* Liaises with AMES Case Coordinator and              Visas
  GP regarding entrant's health needs
* Meets with GP and consults with AMES
  Case Coordinator about Team Care                                                                                                                                                                                                                                                                                                                                                                                                                                          * Proactive
  Plan (Service Coordination Plan)                                                                                                                                                               Community Health Centre

General Practitioner (GP)                                                                                                                                                                           Hospital Emergency                                                                                                                                                                                                                                                      * Reduced
* Receives health information from                                                                                                                                                                     Department
  RHN/CHN, Clinic Nurse or AMES Case             Asylum Seeker
                                                                                                         Attempts to apply for Refugee Status
                                                                                                                                                                                                                                                                    All health and social needs met by voluntary medical, legal and social assistance, who provide assessment, care planning and treatment through donated resources,                                         Duplication
  Coordinator                                    (Bridging Visa                                                                                                                                                                                                                                                                 at Asylum Seeker Resource Centre or equivalent
                                                     A or E)
* Conducts MBS Refugee Health
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            * Effective
* Refers to appropriate tertiary or                                                                                                                                                                                                                                                                                                                                                                                                                                           Communication
diagnostic                                                                                                                                                                                                                                                                                                                                                                                                                                                                    & Feedback
  centres (minimising the number of
  appointments for the entrant where
  possible)                                                                                                                                                                                                                                                                                                                                                                                                                                                                 * Appropriate
* Liaises with RHN / CHN and AMES Case                                                                                                                                                                                   * Refugee Health                                                                                                                                                                                                                                     Training &
  Coordinator in regard to results, follow-up                                                                                                                                                                                                                              MBS                                                                                                                            SCTT
                                                                                                                                                                                                                           Assessment &                                                                                                                                                                                                                                       Education
  treatment and care planning                                                                                                                                                                                                                                           * Refugee                                                                                                                       * GPMP
                                                                                                  * Pre-                                                                      AMES                                            SCTT
                                                                                                                                                                                                                                                                          Health                                                                                                                          * TCA                                    SCTT
                                                                                                Departure                                                                    * Holistic                              * Consumer Consent to                                                                                                          SCTT
                                                                                                                                                                                                                                                                       Assessment                                                                                                                   * Organisational                             * Service
Tertiary Hospital Clinics
* Conduct appropriate tests and
                                                    TOOLS                                        Medical                                                                  Assessment &                                  share information
                                                                                                                                                                                                                                                                                                                                                 * GP Referral
                                                                                                                                                                                                                                                                                                                                                                                                         Profiles                               Coordination
                                                                                                  Screen                                                                  * Complexity                                * Confidential Referral                                                                                                      Template
  screening for specific disease conditions                                                                                                                                                                                                                               SCTT                                                                                                                        * Functional                                 Plan
* Liaise closely with GP in regard to                                                            (PDMS)                                                                        Tool                                         Cover Sheet
                                                                                                                                                                                                                                                                      * GP Referral                                                                                                                   Assessment
  results and follow-up treatment                                                                                                                                                                                    * Consumer Information
* Implements Care Pathway principles                                                                                                                                                                                                                                    Template                                                                                                                       Summary
                                                                                                                                                                                                                      * Summary & Referral

Specialist and Allied Health
* Conduct specialised assessments
  as requested
* Liaise with GP in regard to follow-up t
  reatment and care planning
* Implements Care Pathway Principles

                                                                                                                                                                                                                                                                                                                                                                                                                                         WestBay Alliance and Brimbank Melton PCPs
                                                                                                                                              DRAFT                                  DRAFT                                 DRAFT                         DRAFT                                    DRAFT                                                                                                                                                Refugee Health
                                                                                                                                                                                                                                                                                                                                                                                                                                                Service Coordination Project
          Enablers of
     Proposed Care Pathway
• An ‘ideal’ pathway – something to aim for?
• May not be achievable immediately, but some
  aspects can be put in place now.
• Has the goal of improved service
  coordination and care planning.
• Based on the Social Model of Health.
• Outlines the roles and responsibilities of those
  involved in the Care Pathway.
• Outlines the Principles underlying the
  implementation of the Care Pathway.
        Enablers of
Proposed Care Pathway cont.
• Indicates different pathways, depending on the
  complexity of the refugee.
• Allows for additional support to be provided
  (eg. by community guides, access workers or
  volunteers) for refugees and their families, who
  have more complex needs.
• Accounts for all visa holders and their various
• Indicates the relevant assessment,
  communication and care planning tools
  to be used (SCTT and others).
        Enablers of
Proposed Care Pathway cont.
• Attempts to reduce number of appointments for
• Utilises the MBS item number for GPs who do a
  comprehensive Refugee Health Assessment.
• Involves referral to specialist services for specific
  assessment and ongoing treatment.
• Incorporates regular, informative discussion
  between GP, Nurse & AMES Case Coordinator,
  to ensure effective case management and care
Developed a Complexity Screen
• To measure the level of complexity and
  urgency in a refugee situation.
• To ensure appropriate levels of support
  are provided for refugees to enable access
  and efficiency of further assessment.
• To encourage communication between
  service providers regarding the specific
  needs of each refugee.
Contents of Complexity Screen
•   Purpose of Tool / Screen
•   General Information
•   ‘Alert’ Health Information
•   Education Level
•   Pre-Arrival Experience
•   Family Composition
•   Living Situation
•   Health Situation
•   Complexity and Urgency Score and Action
•   Professional Judgement
  So how does all this relate to
        Care Planning?
• Refugee Care Planning could not be done
  well, if this process had not occurred.
• The steps in this project have established
  a solid foundation for care planning.
• Key Principles:
  – Interagency collaboration and useful
  – Willingness to change if it makes access
    easier for the client
  – Keeping the client and their circumstances at
    the centre of the planning
          Essential ingredients
         for good Care Planning
• Outlined in the Principles underlying the
• success of the Refugee Care Pathway:
•   Client focused and empowering
•   Informed consent and privacy
•   Culturally sensitive and respectful
•   Information provision and sharing
•   Partnership – including refugee
•   Collaboration between agencies
    and client
         Essential ingredients
     for good Care Planning cont.

•   Shared responsibility
•   Strengths based
•   Proactive approach
•   Reduced duplication
•   Effective communication and feedback
•   Appropriate training and education
Thank You!

          WestBay Alliance
      Brimbank Melton PCP

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