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

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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