Delivering healthcare to refugee communities in regional NSW

Barriers and enablers

Health staff from local services share the barriers and enablers to establish a regional refugee health service in NSW.

Key considerations for current refugee health services include:

funding models
staffing
physical environment
community culture
access to specialists, primary care providers, and transport for patients and carers.

Enablers and barriers to working with people from refugee backgrounds

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Enablers

Develop strong relationships with settlement providers, primary health, allied health and community health partners to ensure an all-of-health response and to address local challenges.
Establish a memorandum of understanding or agreement with key agencies and settlement service providers to identify clear roles and responsibilities to meet common outcomes.
The local health district (LHD) executive team provides active sponsorship, leadership and governance over the service.
Identify health system champions to ensure staff feel supported to manage their clinical case load, with clear lines for management to address local system challenges.
Enhance knowledge sharing with community health partners who have a shared understanding of the health needs of people from refugee backgrounds. For example, share referrals to local optometrists who may provide free optical healthcare due to agreed contracts with a health service to ensure there are no out-of-pocket expenses for the client.

Facilitate home visits to enable nursing staff to assess the home environment, identify potential domestic issues or opportunities that could impact care. House visits generally occur between two and four weeks of the arrival of the new cohort. This delay allows settlement services, housing, education and Centrelink to begin their services. Clients with complex needs may be seen sooner.
Allocate physical space to assess clients in a friendly, warm and engaging atmosphere that has cultural significance. For example, display artworks and photographs of community members.

Facilitate access to immigration information to inform local health staff of the number of new arrivals, demographics and cultural needs to support local service planning.
Where possible, establish a multidisciplinary team, including a social worker, physiotherapist and occupational therapist. The teams should have a shared understanding of the clinical needs for refugee communities. This will enhance the breadth of care by providing holistic and specialised care. Multidisciplinary teams depend on funding, staff availability and chief executive support.

Use clinical assessment templates that are designed to ensure assessment is streamlined and tailored to the needs of newly-arrived refugee communities.
Provide training that is relevant to emerging diseases and health conditions specific to the refugee community. Ensure it is completed and attended consistently. This can depend on the needs of staff, but is important when new staff join the refugee team.
Ensure wellbeing resources, training and support services are readily available to protect and promote healthy working environments.

Staffing and skills required

When setting up a refugee health service, staff with the following skills and credentials should be considered:

Administration or clerical staff
Clinical nurse consultants
A paediatric specialist (children make up nearly 50% of Australia’s humanitarian intake^*)
A team of general practitioners (GPs) for ongoing care
Social workers
A multicultural liaison service
Bicultural workers to provide insight into community needs or lived experience
Occupational therapists to help manage applications for the National Disability Insurance Scheme (NDIS)

Two children from Myanmar at the pathology clinic in Coffs Harbour. Children make up nearly 50% of Australia’s humanitarian intake.

Barriers

Staff from established refugee health services identified the following barriers to delivering effective healthcare to people from refugee backgrounds. They also recommend strategies to overcome these challenges.

Barrier	Strategies
Limited access to healthcare interpreters in appropriate and emerging languages, especially for minority groups. Interpreters not always used in GP or specialist settings.	Access the NSW Health Care Interpreting Services. Use the Commonwealth Translating and Interpreter Service (TIS) to access interpreters in more languages over the phone. Partner with the primary health network to provide education and information sessions to GPs about engaging interpreters. Explain the risks of not working with interpreters; for example, incorrect diagnosis or using children to interpret.
Lack of free access to specialist care for some clients.	If bulk billing specialists are not available, locate specialists inside hospital settings, if possible. Encourage the use of virtual care to service providers who do bulk bill.
Fluctuations in settlement numbers creating challenges in funding, recruitment and retention of experienced staff.	Liaise with the NSW Refugee Health Service and the NSW Ministry of Health to understand how the local services can be involved in the planning for settlement, to ensure the service is adequately resourced.
Refugee cohorts with high healthcare needs settling in regional areas that have limited access to specialist healthcare services. Limited access to transport for specialist appointments or out-of-area care, including tertiary hospitals and the Sydney Children’s Hospital Network.	Ensure you have a good relationship with disability services (e.g. paediatric and dental care). Non-government organisations can offer transport support for refugee communities by seeking grant funding. Contact the NSW Refugee Health Service for support.
Completing NDIS applications and wait times to use disability service providers.	Dedicated staff within your team (such as an occupational therapist) could provide support to complete NDIS applications, where possible. Staff should develop a relationship with a chosen disability service provider. This will ensure continuity of care and management of clients when funding becomes available.
Violence, abuse and neglect within the community may inhibit access to clinical care. The notion of abuse may not be understood culturally, in language or through translation. Safety fears for a client and their family, and challenges around reporting.	In addition to the mandatory child wellbeing and child protection training, refugee health teams should complete additional training on working with refugee and culturally and linguistically diverse communities. This will help build capability for staff to identify violence, abuse and neglect and refer clients in a culturally safe and trauma-informed way. The NSW Health Education Centre Against Violence provides information, resources and training.
Access to early childhood programs for those born overseas, as they don’t get a 'Blue book' or enter early childhood programs, compared with children born in Australia.	Partner with your local community health, child and family health team to ensure children are screened and cared for. Ensure this care goes beyond the vaccination program.
Inconsistent engagement with GPs across regional settings, due to workforce constraints and areas of specialty or interest. Some practices have long wait times due to supply and demand issues.	Liaise with your local primary health network to explore partnership options. Establishing a nurse-led clinic can ease the pressure on GPs needing to do the initial care and assessment.
Some refugee cohorts or community members move, often to other settlement areas. This is referred to as secondary settlement.	If you work with a client or family who has relocated from another area, ensure you request patient information (with their consent) from the previous local health service to ensure continuity of care.
Stigma associated with accessing mental health services based on cultural beliefs.	Host information sessions within your local refugee health team, and with bicultural workers and interpreters to ensure clients are educated on what mental health is and how to access mental health services. The Transcultural Mental Health Centre has specialist positions and resources to help with this.
Health staff working beyond their contractual obligations to address the needs of the community.	Promote a collaborative, shared response to the refugee health service in small communities. See Staff training and wellbeing.
Clients missing specialist appointments because reminders are not in their language or interpreters are not used.	Work with specialists and their administrative teams to ensure appointment reminders are forwarded in a way that meets patient needs. Explain how they can appropriately access health appointment reminders.
Turnover of health staff due to managing high caseloads and challenges supporting clients with high needs.	Ensure all staff have access to wellbeing support and training. Refer to Staff training and wellbeing.
Misunderstanding cultural considerations when caring for certain community groups.	Encourage staff to undertake the relevant training to understand the cultural-safety implications and nuances in working with people from refugee backgrounds. Ensure all staff have access to appropriate and relevant training and wellbeing resources.
Some patients are surprised by wait times to access specialists.	During your early information sessions with settlement service providers, talk about the Australian healthcare system and set expectations around specialist referrals, wait times, and private and public models of care.
Some people arrive in Australia without medications for chronic illnesses, such as diabetes. Others can arrive dependent on illicit drugs that were readily available in refugee camps or their country of origin. This can create complexities for initial treatment and ongoing healthcare.	During initial assessment, discuss the person's use of medication and other substances prior to arriving in Australia. Ensure this informs the healthcare team about current and ongoing medication needs.
Communities are not always engaged in the planning process, service design or improvement to service delivery.	Promote consumer engagement wherever possible. Find out more about building the foundations for effective consumer partnerships and engagement.

Augustine was one of many people who shared how important it is to have access to transport to attend appointments for specialist care.

David's story: barriers for people with complex needs

David was born in 2006 in Iraq. His family is of Yazidi ethnicity.

David’s father and siblings (other than one sister) were taken by ISIS in 2014 and were presumed dead.

In March 2019, David, his mother and 19-year-old sister settled in Coffs Harbour, NSW. They had family members already living in Coffs Harbour, but they had settlement and health problems of their own and could not support the family.

David was diagnosed with Duchenne muscular dystrophy (DMD) in Iraq. He uses a manual wheelchair and relies on his mother for all his daily activities. In July 2019, several appointments were organised at John Hunter Hospital (JHH) with multiple specialists to optimise David’s visit.

An inter-hospital transfer was declined due to cost. There are no direct flights between Newcastle and Coffs Harbour. Passengers need to fly to Sydney then back to Newcastle. Flights were organised but the airline refused to book them due to the mother and son’s inability to speak English. The airline said they must travel with a bilingual guide. Mid North Coast Local Health District employed a bilingual worker to escort the family to JHH.

They left Coffs Harbour at 10am on 22 July and did not return at until late afternoon on 25 July. This included more than 10 hours of travel time across three days.

The family was assisted to and from the airport in Coffs Harbour by their case worker from Settlement Services International (SSI). In Newcastle, they were picked up by a clinical nurse consultant connected with one of David's specialist services.

The long journey was exhausting and stressful for David’s mother who had to support David for all his daily needs. It was also expensive. Public health had to pay for the bilingual guide, flights, accommodation, food and a wage for three days.

The logistics of the trip were extensive. Nursing staff and social workers from both Coffs Harbour and John Hunter Hospitals spent many hours liaising with SSI, the patient and mother using interpreters.

Fortunately, this year, David’s NDIS package has been put in place so his most recent visit to JHH involved a support worker driving him and his mother to Newcastle. This was a far more comfortable journey for the family.

In July 2022, David's family received news that four siblings had been found alive. It is hoped they can relocate to Australia soon.

^* Australian Refugee Health Practice Guide. Children.

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