Local case study – Hunter New England Local Health District

Newcastle and Armidale Refugee Health Services

1 Oct 2022 Reading time approximately

A nurse-led service with a medical clinical lead to provide specialist care.

Location of services Newcastle and Armidale
Patient demographics

Newcastle: Afghanistan, Iran, Iraq, Myanmar, Syria and some asylum seekers

Armidale: Ezidi (Northern Iraq)

Note: The Northern Iraqi community in Armidale identifies as Ezidi and not Yazidi. There may be references to Yazidi communities in other areas of this project when talking about communities in other locations. Although Ezidi and Yazidi are from the same area of Northern Iraq and the same cultural backgrounds, they may be referred to differently in different locations.

Information processes

Newcastle stores clinical information in Cerner (electronic medical record).

Armidale uses CHIME as the system is designed for community health settings.

Governance structureThe service manager sits in the Hunter New England Local Health District multicultural health unit, based in Newcastle, and reports to the executive director, clinical services, nursing and midwifery.


All clients are assessed by a specialised refugee nurse within 28 days of arrival. The service begins with a home visit to assess and triage complex needs. It is followed by:

  • an in-depth medical assessment
  • treatment of health conditions
  • full immunisation schedule and catch up
  • early referral process to specialist and mainstream health services, such as pathology, dental, physiotherapy, speech pathology, child and family health teams, and maternity services.

The service also supports National Disability Insurance Scheme applications and assessments.

It runs a drop-in clinic, with support from the Adult Migrant English Program provider, offering health education and advocacy sessions.

It also provides clinical training and support for mainstream health services.

Promotion strategies

The refugee health service is promoted during community health expos, National Refugee Week activities, seminars and conferences.

The settlement agency runs education sessions such as:

  • an orientation to the healthcare system
  • how to access the healthcare system
  • the healthcare rights of refugees
  • information about child protection, parenting and domestic violence.

Resources and information are provided in the language of the people from refugee backgrounds and supported by the Multicultural Health Liaison Program.

Making a difference

    It takes time and patience to provide services to newly arrived groups. Trauma-informed care is essential and poorly understood by mainstream services.

    Our service understands their complex health needs. We overcome cultural barriers by networking with other refugee health teams, accessing trauma-informed training run by NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) and increasing our awareness around cultural needs and sensitivities. We also provide education and support to mainstream services.

    Top tips

    As soon as possible

    • Gather knowledge about the number of new arrivals. This aids settlement planning. Fluctuations in cohort numbers can create challenges in funding, recruitment and retention of experienced staff.
    • Establish a multidisciplinary team that has a diverse range of clinical expertise. This will enhance the breadth of care provided.
    • Tailor medical assessment templates to support nurses and medical staff to assess clients and create a centralised database to house the information collected.
    • Gain access to trained healthcare interpreters in the correct and emerging languages. This is critical for healthcare success.

    Build relationships

    • Develop strong relationships with general practitioners as much of the work is offered pro bono and depends on goodwill.
    • Enlist the primary health network to champion the importance of primary health for your clients.
    • Establish a memorandum of understanding or agreement with your settlement service provider to ensure that there is shared purpose and agreed roles and responsibilities.

    Create broad support

    • Generate ongoing sponsorship from the local health district leadership. The leaders make decisions around staff investment, retention and support resources.
    • Establish an advisory group. In the Hunter district, this was created when the refugee health service was set up. It includes representatives from local dental, emergency, maternity and paediatric services as well as the NSW Refugee Health Service. Networking across clinical groups creates a platform to address system challenges, share ideas and learn more about arriving cohorts.
    • Establish a multicultural access committee (MAC) for each large service or district sector where refugees access healthcare. Issues can be raised at the MAC. There are nine MACs and each MAC is chaired by the service or sector general manager.

    Visit the Hunter New England Local Health District's Multicultural Health Service's website.

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