The Philadelphia Refugee Health Collaborative was established in 2008, under the leadership of Nationalities Service Center (NSC), to create an equitable system of refugee health care in the Philadelphia region. Consisting of eight refugee health clinics and the three local refugee resettlement agencies, the Collaborative has made significant progress towards that goal. The Collaborative model is a unique model of care for refugees in the US. Key components of the model include close partnerships between resettlement agencies and medical providers, location within large university health systems and coordination between resettlement agencies. Since its inception, the Collaborative has increased its capacity for refugee screenings by over 220% (from 250 screenings annually to 800 screenings annually).
Issue: Since the mid-1970s, large numbers of refugees have been resettled in the Philadelphia region. Between 1983 and 2004, 33,000 refugees were resettled in the Delaware Valley. Currently, three local resettlement agencies—Nationalities Service Center, Lutheran Children and Family Service (LCFS) and Hebrew Immigrant Aid Society and Council Migration Service—are resettling approximately 800 refugees to the region each year. Refugees typically come from many years of living in refugee camps or urban slums with limited access to health care, food, clean water and hygiene. Many refugees arrive with unmanaged, chronic health conditions and/or infectious diseases including heart disease, hypertension, tuberculosis (TB) and hepatitis. Refugees also experience emotional trauma resulting from war, displacement and loss of loved ones and status, and they are frequently diagnosed with depression, anxiety, and post traumatic stress disorder (PTSD). Eager to begin anew but struggling with limited English proficiency and limited understanding of the complex US health care system, refugees need help navigating the health care system.
According to federal protocol, refugees must obtain a domestic health screening (immunizations and screening for TB, infectious diseases, parasites, PTSD) and orientation to the US health care system within 30 days of arrival. The screening process is typically facilitated by a state department of health or state refugee coordinator, but no such system exists in Pennsylvania. Until about five years ago, local resettlement agencies struggled to find medical providers with the cultural competence and knowledge of refugee health needed to provide high-quality screenings and follow-up care. In the absence of coordinated partnerships with medical providers, resettlement agencies employed an ad hoc system of referring refugees to local private physicians and public health centers. However, public health centers are so overburdened that it can take months to secure a screening appointment.
Best Practice Research: The Centers for Disease Control publishes guidelines for the screening of recently arrived refugees (http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html). These guidelines focus almost exclusively on diagnosis and treatment of infectious diseases such as tuberculosis, lead exposure and malaria. In recent years, increased discussion among medical providers conducting refugee screening has brought to light the need for more comprehensive screening including complex medical issues, mental health concerns and chronic diseases including diabetes. According to recent research published by Bishop et al. (2012), refugees arriving in Philadelphia demonstrate rates comparable to national rates of chronic disease, particularly Iraqi and geriatric refugees.
Furthermore, recent research on the patient-centered medical home movement is currently at the forefront of best practices in primary care medicine. This model utilizes the primary care office as the home base for patient care. By placing the Philadelphia Refugee Health Collaborative clinics in large hospital systems with extensive access to specialized testing and specialty care, we are able to provide comprehensive health management to all refugees, particularly those with complex needs.
Case Study: In 2012, JU, a 53-year-old refugee from Bhutan arrived in Philadelphia. She had lived in a refugee camp in Nepal for over 20 years after being forced out of Bhutan. With limited to access to medical care in her small village, JU was struck with rheumatic fever at an early age. With only basic medical care available in the camp, JU eventually developed rheumatic heart disease, which weakened her heart valves. She was unable to perform basic daily activities; she was even so weak she was unable to stand to cook dinner for her family. Upon her arrival in the US, JU was screened by a partner PRHC clinic, where she was referred for an urgent cardiology appointment. Two weeks after her arrival, she was seen by cardiology within the hospital network, where she was referred for valve replacement surgery. She completed surgery two months after arrival and is now recovering at home, where for the first time in many years, she is able to walk without assistance. JU will be followed for ongoing care in the medical home at the PRHC clinic.
Partnership Model: In 2007, NSC and Jefferson Family Medicine Associations piloted a refugee health clinic model involving a close partnership between a resettlement agency and a medical provider. Since 2007, the Philadelphia Refugee Health Collaborative has led efforts to replicate and adapt this clinic model to establish additional refugee clinics in Philadelphia. Key elements of the refugee clinic model include:
- The medical provider establishes a weekly clinic dedicated to refugees.
- The medical provider and resettlement agency develop a scheduling and registration system and have regular biannual meetings to evaluate clinic functioning.
- The resettlement agency designates a staff person to function as the “Clinic Liaison” to escort new patients to the clinic, troubleshoot registration issues, complete immediate scheduling of follow-up specialist appointments and help new patients fill prescriptions. The clinic liaison acts as the point person for communication with the clinic staff regarding patient care.
- The medical provider completes the required domestic health screening and provides immediate attention to chronic and acute health needs and ongoing primary care.
- The refugee clinic provides resident training in global health and cultural competency.
- Patients have access to an extensive network of specialty practices through the university health system.
These clinics currently have a capacity to serve all incoming refugees including 19 new adult patients per week and 14 new pediatric patients per week through a network of eight clinics. These include:
- Children’s Hospital of Philadelphia–Coordinated by Hebrew Immigrant Aid Society
- Einstein Community Practice–Coordinated by Lutheran Children and Family Services
- Einstein Pediatrics–Coordinated by Lutheran Children and Family Services
- Drexel Women’s Care Center–Coordinated by Nationalities Service Center
- Fairmount Primary Care Center–Coordinated by Nationalities Service Center
- Jefferson Family Medicine Associates–Coordinated by Nationalities Service Center
- Nemours Pediatrics–Coordinated by Nationalities Service Center
- Penn Center for Primary Care–Coordinated by Hebrew Immigrant Aid Society
Initially, new clinics formed in partnership with one specific resettlement agency. However, this meant that newly arrived refugees in Philadelphia did not have equal access to care. For example, until 2011, refugees resettled by LCFS were not connected with any of the refugee health clinics and were still receiving ad hoc referrals to community health centers. Since April 2012, all clinics accept regular referrals from all three resettlement agencies, resulting in a more equitable system of health care for all newly arriving refugees.
The Philadelphia Refugee Health Collaborative has been funded in recent years by the Barra Foundation, which provides funding for a coordinator who facilitates quarterly meetings among all partners, coordinates refugee health staff at the various resettlement agencies and liaises with city and state departments of public health. The Collaborative meets formally on a quarterly basis to discuss best practices, challenges and future opportunities. Additionally, clinicians and resettlement staff communicate on a daily basis to discuss challenging cases and share successes. It is important to note that the Collaborative does not provide funding above Medicaid reimbursements to clinicians. The success of the Collaborative relies on a core network of champions at the eight provider clinics. Currently the Collaborative is undergoing a strategic planning process to determine the future direction of the initiative.
Compared with five years ago, refugees arriving in Philadelphia are getting faster access to screening, specialist and primary care; more comprehensive and higher-quality screenings by physicians who specialize in refugee health; and targeted health education and support to enable independent navigation of the health care system. From an original capacity of 250 new refugee patients per year in 2007, PRHC clinics now provides domestic health screenings, primary care (including newborn, pediatrics, adult medicine, geriatric and obstetric and gynecologic care) and access to laboratory, radiology and subspecialty services to up to 800 newly arrived refugees each year as well as ongoing primary care for established patients and a specialized refugee women’s health clinic.
Gretchen Wendel is the refugee health coordinator for the Philadelphia Refugee Health Collaborative. Ms. Wendel has been working with vulnerable adults in Philadelphia for over seven years. Her work initially began with men and women transitioning from welfare into work. In recent years, she has returned to work with immigrant and refugee populations through her tenure at Congreso de Latinos Unidos and her current work at Nationalities Service Center. During her first two years at NSC, Gretchen served as a member of NSC’s health team and worked to expand health resources and develop processes to ensure that refugees have access to a full range of health services. She then served as the case manager for the Survivors of Torture Program at NSC, providing needed support services to this especially vulnerable population. Gretchen Wendel is the 2011 recipient of the Unsung Heroine Agency Award from the Women’s Way.