Razing Barriers: Brokering Access to Care for Refugee and Inner City Populations

Transcription

1 Razing Barriers: Brokering Access to Care for Refugee and Inner City Populations Trauma Talks Conference 2014 Dr. Neil Arya, MD Dr. Josephine McMurray, PhD

2 Acknowledgements Social Sciences & Humanities Research Council of Canada through a grant from the Centre of Excellence for Research on Immigration and Settlement (CERIS). Internal grant from Wilfrid Laurier University Western University Global Health Office for administering grant and logistical support We would like to thank the staff and clients of both facilities where have conducted our research

3 Agenda Introductions The context : Poor health related to trauma Barriers to care for newly arrived refugees and those whose shelter is at risk Models of care using non medical brokers in these settings Promoting autonomy and participation building resilience & social capital Novel international approaches to trauma care Discussion

4 Good health starts with social cohesion & equity Countries with low education & income poor health Citizens within countries with low education & income Mathews, J. (1998) The Menzies School of Health Research offers a new paradigm of cooperative research. Medical Research Perspectives, 169 (11):

5 Canada struggles with its understanding of equity & good health June 30, 2012 Interim Federal Health program revoked for most refugees entering Canada (unless condition is public health or safety concern) Impact on refugees: Foregoing treatment even in emergencies Incurring bills that can t be paid Pregnant women unable to access essential pre natal care Children not receiving care

6 Understanding Power Relations Power and Privilege In the process of enhancing our cultural competence, it is important to recognize the type of power that surrounds our privilege (whether or not we feel powerful). In society, the privileged group has the power to: Act and define reality Determine what is normal and correct Institutionalize and systematize discrimination (Nova Scotia Department of Health, 2005)

7 Feeling Poverty Poverty is like heat; you cannot see it; you can only feel it; so to know poverty you have to go through it. -An old man, Adaboya, Ghana Poverty is pain; it feels like a disease. It attacks a person not only materially but also morally. It eats away one s dignity and drives one into total despair. -A poor woman, Moldova (World Bank, 2000a), Quoted in Medact Global Health Curriculum

8 two populations, two models of care

9 So different and yet the same Population Experience of trauma Refugee Health Clinic 300 government assisted refugees (GARs) annually Secure shelter (reception house) Unemployed (limited capacity language, education) Diseases of deprivation Complex physical & mental health needs Low social capital 94% No (no PERSONAL torture or physical threat) Resilient but fragile Psychiatric Outreach Clinic 1200 client, 550 active, 50 concurrent disorders patients Shelter at risk Unemployed (and limited capacity?) Diseases of deprivation PLUS Concurrent disorders mental health & addiction Low social capital Majority report some Resilient but fragile Gender 56% Men, 44% Women Majority are Men Language 79% No to Minimal English English (Majority) Relationship with traditional care systems High needs i.e. language Difficult to diagnose, manage and treat Support from multiple support systems High needs i.e. early mortality Unwelcome in regular clinics 80% don t have primary care provider Support from multiple support systems

10 Capacity Building Model Medical care Highly motivated, culturally sensitized, integrated Support Service Networks Informal Formal Social Capital Community Ownership of space System Brokers

11 case study one refugee health clinic

12 Where they re coming from Dadaab camp, 1992 Dadaab Camp, 2002

13 Where they re coming from Dadaab Camp, ,000 refugees

14 Where they re coming from Refugees face three possible solutions: Repatriation Local integration Resettlement Most remain in camps

15 Top 10 source countries MYANMAR 225 IRAQ 154 SOMALIA 135 AFGHANISTAN 85 COLOMBIA 83 THAILAND 62 BANGLADESH 61 SUDAN 54 ETHIOPIA 53 CONGO (DRC) 49 TOTAL 1234

16 Refugees face many barriers to care Individual Financial Language Cultural understanding of disease Burden of disease & complexity Experience of trauma Transportation & logistics Institutional Knowledge of entitlements Translation Provider knowledge of disease Operational workflows Appropriate referrals Bureaucratic burden System Level Funding Availability of trained professionals Cultural boundedness Lack of system coordination Rigid policies Barriers to Care (McMurray et al., 2013)

17 Reception Centre Provides settlement services to GARs for first year, first 3 months residential Staff carry out a wide array of settlement programs and services funded by Citizenship & Immigration RAP, Life skills, CSS

18 Refugee Health Clinic Co created by non medical staff & partnership with family health team Skilled, comprehensive healthcare until permanent primary healthcare provider identified Health system navigation & coordination provided by Reception House case workers i.e. accompaniment to appointments, translation Collaborative network with likeminded community health service providers i.e. optometry, pharmacy etc.

19 Timeline and flow for refugee health services

20 Community partner network is key

21 What we learned 1.Barriers to care can be overcome with specialized clinics Engaged community based health care providers in partnership with settlement services are key System level barriers (provider shortages, payment/funding difficulties). Organizational barriers (provider knowledge, willingness to treat, sensitivity to power relations). GARs more likely to be treated by GP Individual barriers (language, complexity, location of care ) still affected issues such as employment (those with English are 2 ½ times more likely to be employed)

22 What we learned 2. Caseworker navigation role is crucial to clinic s success Caseworkers coordinate care, arrangement for translation services, accompany clients for increasingly medically complex refugees Transitional support is crucial to successful integration into the regular healthcare system Informal and formal provider networks ensure local providers are aware of need

23 What we learned 3. Health professionals working in collaboration with Systems Brokers helps achieve optimal outcomes Ensure refugees access knowledgeable care in a timely fashion on arrival. GARs were 18% more likely to find a permanent family physician Help patients and community physicians with transitions to carers outside the integrated model Provide administrative and clinical support and advice to other providers i.e. billing, language translation, care guidelines Decreased wait times to see a provider by 30%

24 What we learned 4. Health care providers have a role to play in advocacy Locate and act as resource to family physicians Collaborate with hospital emergency and public health more responsive Networks of care city, social services Integration of allied health services such as pharmacy and optometry services

25 case study two psych outreach clinic

26 Capacity Building Model Medical care Highly motivated, culturally sensitized, integrated Support Service Networks Informal Formal Social Capital Community Ownership of space System Brokers

27 About 35% of streetinvolved individuals have mental health issues 20 25% of the homeless suffer from concurrent disorders Many struggle to engage with mainstream healthcare

28 Frugal innovation 32 clinic hours per week FFS & community funding Free services support social needs co located showers, laundry, gently used clothing, daily meal, food pantry distribution, social interaction (conversation, celebrations, funerals), public phones, volunteering opportunities Low cost care relies on highly skilled professionals to assume calculated risk Innovative care model emerges from front lines in response to need

29 Relationships drive all aspects of care Traditional, centralized, and formal medical models of care have failed this population community based care Non judgmental walking with patients Relationship trumps professionalism Everyone is listening building trust trumps action Circles of care non hierarchical, spontaneous, distributed knowledge, multiple perspectives build a more accurate story to understand and serve the needs of patients

30 Strong organizational values influence care Patient controlled care network patient preferences central to service delivery model walking with Lack of institutionalization & bureaucracy relies on high organizational social capital interpersonal trust, number and quality of network relationships Values based service delivery challenges predominance of facts over values in medical care Practice focussed on compassion, beneficence, careful communication, patience (Little, 2002) Ownership of space belongs to the community not the clinic Restitution of power imbalance we don t say no, flexible systems

31 Large, emergent informal networks build virtual organizational capacity Small organization footprint that relies on personal and professional relationships coalitions with like minded individuals in the network i.e. optometrist providing pro bono service, Staff support to patients where they are mental health court, drug court Networks established and sustained through reputation of staff and organization expertise, commitment, understanding the client culture, effectiveness

32 What we learned 1. Integrating formal medical and informal community based care models is challenging Shared vocabularies must be developed around values, care models Risk mitigation challenges frugal innovation Model is viable due to shared vision and values voluntary contribution of hours & modest pay rates Regional integration to deliver one standard of care and single entry into the system versus grassroots expertise

33 What we learned 2. Community needs are highly contextual and may not scale The population needs vary considerably by geography little economy of scale Relationships are everything frequent and high quality contact Oral tradition of knowledge dissemination and communication has suited frugal service model Aging population, rising rates of cognitive impairment and financial crisis will increase clinic demand

34 What we learned 3. System Brokers help to scale barriers to care for this vulnerable population Serve as family where there is none Identify need as it happens and helps ensure timely access to required services Streamline transitions between and encounters with mainstream healthcare providers for those willing to engage Take care of another friggin form for those who don t trust bureaucracy At the heart of large informal and formal networks of supportive service providers i.e. legal, psycho social

35 4. Registered healthcare professional s practice differently Non hierarchical, multi disciplinary teams are unanimously and enthusiastically endorsed by all providers care from the collective Grassroots model appeals to those wanting more autonomy, freedom from thick policy & procedure manuals that come before real care Formal health records maintained but spontaneous, frequent, oral communication is essential for this population Professional outliers What we learned Focus on listening and developing trust, before treatment

36 What we learned 5. Uneasy truces between traditional healthcare practice and innovative models of care High organizational social capital replaces many formal internal controls distributed and formal organizations are costly and require different expertise the way of working is shared and influences nonprofessional and professional practice Needs of patients/visitors drive staff to adapt systems that have previously been barriers to care Highly autonomous and assess personal risks in situ

37 POP staff person says when organizations and sectors decide to think outside of the box to management health problems, and when they trust their staff enough to give them the freedom they need to respond to health needs in timely and creative ways that meet the standard of care

38 mutual respect is contagious

39 Discussion What other components are crucial for culturally competent and trauma sensitive care? How do these models compare to the service delivery models you use?

40 lhealth Reach Sri Lanka study sites l History of Local Conflict

41 lch lstudy of Health Effects, Sri Lanka

42 lstudy of Health Effects, Sri Lanka Batticaloa (eastern Sri Lanka) two ethnic Muslim and two non Muslim communities were studied Findings 41% victims of conflict related violence (homes attacked, shot at, beaten or arrested) >90% disrupted schooling, displacement of home 15% forced separation from parents (>one month) 89% direct exposure to shelling, shooting and/or bombing 80% extreme poverty & deprivation due to war 53% have seen dead bodies 19% family members disappear 95% experienced death treats 20% score severe/very severe for PTSD, depression & unresolved grief lch

43 lbutterfly Garden

44 lbutterfly Garden

45 lbutterfly Garden

46 lch lbutterfly Garden

47 lbutterfly Garden programs/

48 Media & Peace Education in Afghanistan

49 lafghan Storybook

50 Meeting of Afghan Leaders

51 Palestinian Adolescents Coping with Trauma (PACT) lwikimedia.org

52 Mental Health and Services in Palestine

53 Bir Zeit (2004)

54 Additional questions? We welcome your comments

55 Please feel free to contact us Dr. Neil Arya Dr. Josephine McMurray