Local case study – Illawarra Shoalhaven Local Health District

Multicultural and Refugee Health Service

1 Oct 2022 Reading time approximately

A nurse and general practitioner collaborative model.

Location of services Wollongong, Shellharbour and Shoalhaven.
Patient demographics

Wollongong: Iraq and Syria.

Shellharbour: African subcontinent, including Congo, Eritrea and Ethiopia, Myanmar (Karen and Chin speakers) and Tibet.

Shoalhaven: Thai Myanmar border, Syria, Iraq, Eritrea, Ethiopia, Iran.

Information processes Electronically stored in CHOC, IPM and electronic medical record.
Governance structure The service manager is part of the Multicultural Health Service within Ambulatory and Primary Health Care. Clinicians within the refugee health team are champions for the refugee communities and their health needs.


The Illawarra Shoalhaven Local Health District (ISLHD) Multicultural and Refugee Health Service (MRHS) aims to meet the needs of the local multicultural population to achieve equitable health outcomes. Established in 2007, the MRHS:

  • improves the knowledge of local health services
  • educates refugees on how to access those services
  • provides health information for the newly arrived community.

The refugee service works collaboratively with the region’s health services to deliver culturally appropriate care by:

  • providing training for health professionals
  • consulting on workforce development
  • consulting on improvement projects and resource development.

Caring for clients

Health sessions are conducted in community and learning settings using interpreters.

The MRHS assesses every person from a refugee background who moves into the LHD. It coordinates care according to an individualised care plan developed by the health team. The plan is based on the:

  • complexity of presentation
  • information provided in the Health Assessment Portal reports
  • supports required.

Staff also:

  • undertake home visits
  • support National Disability Insurance Scheme applications
  • collaborate with general practitioners to ensure comprehensive healthcare coordination.

All clients are provided with a plain language and/or translated copy of the patient rights and responsibilities information sheet.

      Staff advocate for people who have newly arrived because they understand there is a broader context to health in terms of advocacy and settlement.

        Community engagement

        Hospital tours are provided for young people from a refugee background and English language students in Wollongong and Shoalhaven. These sessions help orientate community members into unfamiliar settings. It enables them to:

        • feel more comfortable
        • get to know staff
        • learn the locations of services.

        To ensure improved community knowledge and to encourage self-determination, the MRHS:

        • produces resources for language groups and makes them available in print, online and as videos
        • uses interpreters to conduct education sessions for specific communities.


        • The MRHS uses the ISLHD improvement and innovation framework undertake quality improvement programs and involve consumers in co-design processes.
        • Feedback from patients about the MRHS is regularly sought and valued. By listening to patients’ experiences, the MRHS and LHD ensure they remain flexible to the patients’ needs.

        People from Arabic and Burmese backgrounds were invited to share their experiences of the service. This provided valuable feedback that informed an action plan for improvement.


        MRHS continues to enhance access and impact through partnership projects and innovative ways of delivering care coordination, including outreach programs. It conducts nurse and social work outreach programs at:

        • TAFE
        • the Adult Migrant English Program provider
        • settlement services.

        The MRHS is promoted within these settings using a simple poster. During these outreach sessions, services can refer clients, or clients can self-refer.

        The MRHS collaborates with other agencies to progress care plans and advocate for clients.

        Coordination of care and working collaboratively with other agencies ensures that clients have access to holistic and comprehensive supports.

        Top tips

        • Unless they are experiencing health issues, health is not always a priority for members of new communities. It is best to stage interventions and information to align with community priorities.
        • Develop a sound understanding of the impact of trauma, protracted conflict and displacement.
        • Understand that bilingual and bicultural staff members improve access to refugee communities and enhance relationships between consumers and service providers.
        • Outreach clinics are important to ensure access for the community and provide a setting for opportunistic education sessions.
        • Establish a memorandum of understanding with your settlement providers early to clarify shared goals, roles and responsibilities.
        • Develop inter-agency networks with key support services and partners. This is an important resource for services in the refugee space. The Illawarra Refugee Issues Forum is a good example.
        • Access the Health Assessment Portal reports. This helps to develop client care plans and determine their needs.
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