Newly arrived refugees are at increased risk of a number of physical and mental health conditions. Sydney Children's Hospital (SCH), The Wollongong Hospital (TWH), SESIH Multicultural Health Service (MHS) and the Illawarra Division of General Practice (IDGP) have developed and implemented a GP-Hospital collaborative care model to provide routine comprehensive health assessment and follow up to all newly arrived refugees, within the catchment area serviced by South Eastern Sydney Illawarra Area Health (SESIH).

In the first twelve months, almost all newly arrived refugees were seen by GPs and had recommended screening blood tests; a significant number of health issues were identified.

Sustainability of the model is supported by capacity building approaches and funding of a Refugee Health Nurse position.

To improve health of newly arriving refugee families through:

• routine comprehensive assessment
• full immunisation of children within twelve months of arrival
• access to ongoing health care

Refugees have high rates of infectious disease; children are at risk of incomplete immunisation, growth and nutritional problems (Davidson 2004a). Early detection improves long-term health, safeguards public health and is cost-effective.

NSW has no coordinated system to ensure routine health assessment for newly arrived refugees.  With limited pre-departure health checks, no immunisation requirement and high rates of asymptomatic conditions, this represents a lost opportunity to improve refugee health status, especially in children, in whom early detection has life-long health implications.

General Practitioners can provide holistic family-centred care to refugees but require support to overcome significant challenges (Davidson 2004b, Tiong 2006).

Approximately 4,000 refugees come to NSW under the Humanitarian Program each year. Around 150 are settled within SESIH; 40-50% are children or youth (DIAC database).

Analysis of data from 3 refugee health clinics in Sydney found only 1 in 5 children arriving in NSW were screened. Of those, 22% were anaemic, 26% had positive Schistosomiasis serology, 12% had current or recent Malaria, 25% were Mantoux positive and 30% Vitamin D deficient (Raman 2007), demonstrating a high yield of heath problems.

Focus groups conducted with 12 GPs in SESIH highlighted challenges with:

• coordination of care
• complexity of consultations
• language & cross-cultural communication
• psychosocial aspects of care
• management of unfamiliar health conditions

Prior to implementation of the model, SESIH had no specialised refugee health care services and no system to ensure routine comprehensive assessment for refugees, as recommended in the Royal Australian College of Physicians guidelines (RACP 2007).

The GP-Hospital collaborative care model is a unique model underpinned by a strong partnership between the IDGP and SESIH. A thorough early health assessment is provided for each family by a network of trained community-based GPs who are aided in accessing NSW-based services by a refugee health nurse liaising closely with hospital-based specialists. This is a cost-effective model (Chih 2006, Schwartzman 2000) that provides seamless transfer of care from the community to the hospital sector. Importantly, the primacy of the early link with GPs ensures families receive holistic, supervised care and a firm foundation for a longstanding health partnership.

The development of the GP-Hospital Collaborative Care Model was informed by needs assessments conducted by SCH (2006/07) and South Eastern Sydney Area Health Service (2001). These included interviews with refugee families, key informants and community organisations.

In 2006/07, the GP-Hospital collaborative care model was created as a partnership between SCH, TWH, the SESIH Multicultural Health Service (MHS) and the Illawarra Division of General Practice (IDGP). The model places a network of refugee-friendly GPs at the centre of care for newly arrived refugee families.

In establishing the model, the network partners have organised:

• Department of Immigration and Citizenship (DIAC) and their contracted settlement services notify SESIH of new refugee arrivals.
• MHS Multicultural Health Worker provides newly arrived refugees with information about the health system.
• IDGP holds and communicates with a register of GPs interested in participating in the model, and hosts regular training sessions.
• Settlement service caseworkers link families with the identified GPs, assisted by the MHS refugee health nurse.
• GPs provide a routine comprehensive health assessment on arrival as well as ongoing care.
• Specialists at SCH and TWH offer support to GPs through education and training forums, regularly updated screening and management guidelines, easy access to consultation and clinical referral pathways, plus opportunities for GP feedback on the model.
• MHS Refugee Health Nurse facilitates communication between GPs and hospital services, supports GPs in coordinating care for complex cases (the linchpin of the Care Model) and in providing immunisation.
• A regular Refugee Child Health Clinic at SCH offering a tertiary referral service for children requiring subspecialty assessments, such as for paediatric infectious diseases, with a community paediatrician co-ordinating their care.
• Periodic infectious diseases clinics for adults at TWH.
• Settlement service caseworkers and the nurse support children and their families to attend clinics.

One hundred and twenty-three newly arrived refugees (Visas 200 and 204) settled in SESIH between March 2007 and February 2008. In the model’s first year, all 64 (100%) children and 95% of 59 adults were seen by GPs and had recommended screening blood tests. 55% of children were under-immunised and received catch up vaccines from GPs; 28% were referred to the refugee child health clinic; 5% were hospitalised.

Consistent with findings from other refugee clinics, significant public health and medical conditions were identified, including Vitamin D deficiency (47% children; 30% adults), Schistosomiasis (16% children; 33% adults), active Hepatitis B infections (8% children; 13% adults), latent TB requiring prophylaxis (8% children; 20% adults) and Malaria (2% combined). Management of these conditions will improve the long term health outcomes of this cohort.

The GP-Hospital collaborative care model has unprecedented capture of all newly arrived refugees. It has developed the capacity of SESIH to respond to the needs of newly arrived refugees. Through partnerships with GPs and others in the public health system, the model has provided a continuum of care, from prevention and early identification through to the management of chronic health conditions, as well as easier transitions between primary health care in the community and hospital-based care.

The collaborative care model was developed using small capacity-building project grants. Strategies such as the development of partnerships with key service providers, and the provision of education and training, clinical guidelines, referral pathways and other resources to GPs will be sustainable over time.

Sustainability of the model has been ensured through the development of a newly created Refugee Health portfolio within SESIH MHS. This role will support the sustainability of the model as a whole, the partnerships that have been developed and the distribution of resources. There has also been considerable advocacy for funding for a Refugee Health Nurse into the long term.

The GP-Hospital collaborative care model demonstrates the ability to engage local GPs and ensure appropriate assessment and care for newly arrived refugee families. The model serves as an example of a successful capacity building approach. It is highly applicable to other Area Health Services interested in working collaboratively with GPs to develop, expand or refine services to refugees or other vulnerable population groups. Utilising GPs to provide initial and long-term comprehensive care both improves the experience for refugees and provides significant cost savings to the Area. Early detection of health conditions and immunising children is cost effective and improves health outcomes.

1. Chih DT, Heath CH, Murray RJ. Outpatient treatment of malaria in recently arrived African migrants. MJA. 2006; 185: 598-601.
2. Davidson N, Skull S, Chaney G, Frydenberg A, Isaacs D, Kelly P, Lampropoulos B et al.  Comprehensive health assessment for newly arrived refugee children in Australia.  Journal of Paediatrics and Child Health 2004; 40: 562-568.
3. Davidson N, Skull S, Burgner D, Kelly P, Raman S, Silove D, Steel Z, Smith M.  An issue of access: Delivering equitable health care for newly arrived refugee children in Australia.  Journal of Paediatrics and Child Health 2004; 40: 569-575.
4. Department of Immigration & Citizenship Settlement Database. 
5. Raman S, Wood N, Iskander M, Webber M, Smith M, Hale K, Taylor K, Isaacs D. Addressing refugee children’s health needs: have we got it right? [Abstract] Journal of Paediatrics and Child Health. 2007; 43: A1-A22.
6. Royal Australasian College of Physicians (RACP). Towards better health for refugee children and young people in Australia and New Zealand: The RACP perspective Paediatric Policy Committee, Royal Australasian College of Physicians. Sydney: Royal Australasian College of Physicians, 2007.
7. Schwartzman K, Menzies D. Tuberculosis Screening of immigrants to low-prevalence countries. Am J Res Crit Care Med. 2000; 161(3): 780-789.
8. Tiong ACD, Patel MS, Gardiner J, Ryan R, Linton KS, Walker KA, Scopel J et al. Health issues in newly arrived African refugees attending general practice clinics in Melbourne. MJA. 2006; 185: 602-606.

Child Health, South Eastern Sydney Illawara Area Health Service
Phone: 02 9382 8189