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Refugee Readiness Workshop: Primary Health Care Part 2: Practical Issues
Daniela Widmer RN Martina Scholtens MD CCFP Mei-ling Wiedmeyer MD CCFP Bridge Clinic Vancouver Coastal Health April 2016
Practical Issues
● Health Insurance
● Interpretation
● Cultural Competency
● Patient must apply
● No mandatory wait, but processing time is 8-10 weeks
● Can expedite in extenuating circumstances
● No Pharmacare while IFH in effect (1 year)
Medical Services Plan of BC
● Provides limited, temporary coverage of health-care benefits
to resettled refugees and refugee claimants
● Funded by Citizenship and Immigration Canada (CIC)
● Administered by Medavie Blue Cross
● Effective for one year for PSRs and GARs
Interim Federal Health Insurance (IFH)
● IFH provides health insurance while the patient waits for
MSP to come into effect.
● After MSP is activated, IFH still covers the cost of
supplemental services (such as dental and vision care) and
prescription drugs for one year.
Interim Federal Health Insurance (IFH)
● Refugees are eligible to apply for IFH upon arrival in
Canada.
● Enrolment is not automatic.
● Refugees can apply for IFH online and mail the application
to the BC CIC office.
● The settlement worker or sponsor usually assists with this.
● Syrian refugees, however, are given an IFH certificate by
CBSA officers at the point of entry into Canada, or issued
one by an IRCC officer shortly after arrival.
IFH Patient Registration
To confirm patient’s coverage:
● locate 8-digit client ID number at the upper right-hand corner
of their IFH document
● enter it into Medavie’s secure provider web portal
● or call 1-888-614-1880
IFH Coverage
As of April 1, 2016, all refugees have full coverage:
● medical care
● investigations
● medications
● supplemental (dental, physio, optometry)
IFH Coverage
● Benefit grids available on Medavie Blue Cross website
IFH Coverage
IFH Coverage: Medical Care
● Family physician visits
● Specialist referrals
● Emergency room visits
● Hospital admissions
● Ambulance services
● Labs and radiology
● Provider must be registered with IFH
● Hospitals are usually registered
IFH Coverage: Investigations
● All medications on BC Formulary
IFH Coverage: Medications
● IFH added benefits (vitamins, anti-helminths)
● Further medications may be covered with Prior Approval
IFH Coverage: Medications
● Dental
o Only emergency relief of pain or infection
oPrior approval required for other procedures
● Optometry
o one eye exam & prescription glasses if needed
● Physiotherapy
● Counseling - limited accessibility
IFH Coverage: Supplemental Services
● IFH directory
● local lists
IFH Providers
Provider registration with IFH
Provider registration with IFH
Provider registration with IFH
Helping patients understand their
health insurance
Patient IFH 101
● Always show your IFH paper anytime accessing care!
● MSP becomes effective within 3 months - show both papers
for 1 year.
● Don’t pay for basic health services - have contact person if
being asked to pay.
o If the patient is billed directly, it is very difficult to obtain
reimbursement.
● MD should note IFH coverage on the prescription or
requisition.
● 90% of Syrians speak Arabic
● 10% speak Kurdish
● 46% of Syrian refugees resettled to Canada in 2014 reported
knowing at least one of Canada’s official languages
Anticipated Language Needs
If you are working from a health authority clinic or hospital, you
can access a phone interpreter 24/7 by calling the Provincial
Language Service (PLS) at 1-888-603-5087 and entering the
site-specific access code.
Some Divisions of Family Practice (e.g. Fraser North,
Vancouver) provide access to PLS for members.
Provincial Language Service (PLS)
● Interpreters through community settlement agencies, need to
be pre-booked
● Familiarize yourself with your community resources
Interpretation
IFH coverage of interpretation costs
● PAHA x 2 hours ($29/h)
● Psychiatry
● Psychotherapy
● Need prior approval
● Not for routine medical visits
Interpretation & IFH
● www.refugeehealth.ca
owomen’s health
omental health
oback pain, etc…
● ask about literacy
Translated Patient Handouts
Visit Logistics
Consider:
● Visit length
● Walk in or booked visit
● Book interpretation services in advance
● Consider family visits - larger physical space
osee family members individually for privacy, especially
women for pregnancy/contraception needs
● Interdisciplinary visits - GP/NP, RN, SW…
● Book patient’s next appointment before they leave
● Debriefing
Mental Health
Among Syrian refugees, the most prevalent mental health
diagnoses include:
● depression
● post traumatic stress disorder (PTSD)
● prolonged grief disorder
● anxiety disorders
Mental Health
● Over 80% of refugees exposed to trauma recover
spontaneously upon reaching safety
● Refugee patients’ mental health benefits from attention to
basic needs such as:
o shelter
o language acquisition
o ability to work or attend school
Trauma
● Guidelines recommend against screening for torture and
trauma
● Be alert for sx of PTSD and depression:
o somatic complaints
o insomnia
o nightmares
● Assess functioning and suffering
● PROTECT Questionnaire
Post Traumatic Stress Disorder
● PTSD typically presents months after arrival
● DSM criteria
● Differentiate PTSD from bereavement, adjustment disorder,
MDE, anxiety
Mental Health
● Use words like “suffering,” “stress” and “nerves” rather than
“depression” or “psychiatric”
● Treatment
o conservative
o sertraline
o counseling
Mental Health Resources
● The Provincial Toll-Free Refugee Mental Health Line (1-
866-393-3133)
● IFH covers counseling by a PhD level registered clinical
psychologist who is registered with IFH, with prior approval.
● Community mental health team or psychiatrist.
Barriers to Care
Individual Driven ● language and culture
● shame, distrust, fear, denial
● financial
● lack of knowledge of system
Provider Driven ● cultural, beliefs
● lack of awareness
● overwhelmed
● lack of financial reimbursement
● lack of support services
System Driven ● Interim Federal health
● “How we do things around here.”
● “A system of permissions.”
Definitions of culture
● Trust
● Health as a low priority
● Resistance to preventive health
● Stigma around mental health
● Cultural sensitivity
Cultural Competency Issues
Specific to Syrians:
● access to female provider for women
● long hospital gowns
● privacy for vaccinations
Cultural Competency
Kindness, humility, curiosity and humour go a long
way towards establishing cross-cultural rapport.
Cultural Competency
Copyright UK Department for International Development, CC license.
www.refugeehealth.ca
Kirby Huminuik,VAST
Session Outline Refugee Readiness Workshop
• Mental Health Concerns for Newly Arrived Refugees
• Screening for Vulnerability
• Brief Psychosocial Interventions
• Working in a Community-based context
• Self-awareness and Self-care
Model of Trauma-Informed Care
Stages of Trauma Recovery Applied to Refugees
Safety and Stability (First year) • Intensity of symptoms subside in most cases
• Attention to orientation and settlement needs
Remembrance and Mourning (Subsequent 2-10+ years) • With stability, loss becomes more acute
• Economic survival, may not prioritize self-care or introspection
• New stresses, losses or traumas can trigger acute symptoms
Reconnection (Lifetime) • Refugees eventually incorporate new cultural, occupational and
relational facets of identity
• Centrality of trauma survivor or refugee identity changes over time
• Chronic symptoms may indicate intensive trauma-focused therapy
Trauma-Informed Care
• Trauma-informed care reflects a comprehensive
understanding of the wide-ranging effects of trauma and violence
• Core values of a trauma-informed practice are safety, trustworthiness, choice, collaboration, and empowerment
• Trauma-informed organizations enact these principles through all of their services and arrange their settings to be protective of client needs
• Not necessarily trauma-focused treatment
Window of Tolerance
Goals for Stage One
1) Safety and Stabilization
2) Acknowledging loss and change
3) Understanding common responses
4) Assessing for more serious concerns
5) Enhancing personal sources of support,
resilience, mental health self-care
6) Strengthening Relationships and Building
new connections
7) Invitation and orientation to future care
Landing and Settling: VAST Group Therapy Program
Optimistic, strengths-based perspective
• Containment, emotional regulation, relaxation
• Sharing experiences and normalization
• A sense of togetherness, solidarity, problem solving,
mutual aid
• Potentially more culturally appropriate
• Effective use of resources
• Counsellor can assess for severity and refer
• Can be used for groups and individuals
Early Intervention: Sources of resilience and support
Inquire about healing people, practices, places, objects:
• Personal and traditional healing practices • Cultural and spiritual practices can also
provide meaning, comfort, stability, and continuity
• Spaces and occasions for refugees to connect with each other for information sharing, mutual understanding, familiarity, support
What are personal healing factors that refugees could connect to here in this new place?
Early Intervention: Invitation & Orientation to Future Care
After the initial arrival, safety and stabilization period: • Most people will settle and experience relative
wellbeing • Symptoms sometimes erupt after people experience
safety – no longer in “survival mode” • Some people will benefit from more intensive and
specialized treatment • Some may experience “retraumatization” after a
period of significant stress
Early intervention sets the tone for future contact with mental health supports
Session Outline Refugee Readiness Workshop
• Mental Health Concerns for Newly Arrived Refugees
• Screening for Vulnerability
• Brief Psychosocial Interventions
• Working in a Community-based context
• Self-awareness and Self-care
Working in Community-based Context
Facilitating Settlement
• Safety and material security is a primary goal
• Refugees are more likely to seek concrete and
practical support (at least at first)
• Settlement workers and counsellors collaborate
• Risks of working in isolation
• Awareness of social determinants of health and mental health: Early life, Disability, Education, Employment, Income, Food
security, Housing, Health services, Gender and Sexual orientation, Race and ethnicity, exposure to violence, discrimination, access to resources, social inclusion (CMHA)
• Importance of a highly coordinated service and support network, with well established referral pathways
• Timely and appropriate referral and follow up
Working in Community-based Context
Interdisciplinary Network
Working in Community-based Context
Working with Interpreters
Competence • Clinical interpreting is a highly skilled task • Ad hoc arrangements (such as family members,
especially children) should be avoided
Confidentiality • Interpreters must be bound by confidentiality
Completeness • The important question is not how “good” or
“accurate” interpretation is, but whether the clinical goals are met
Collaborative • Complex power relationships among client,
interpreter, and clinician can affect what happens in sessions
• Both clinician and interpreter must understand the complexities of interpreting and work together as a team
Neutrality • “Give no advice, insert no opinions” • Cultural consultation – untranslatable idioms of
distress
Working in Community-based Context
Working with Interpreters
Session Outline Refugee Readiness Workshop
• Mental Health Concerns for Newly Arrived Refugees
• Screening for Vulnerability
• Brief Psychosocial Interventions
• Working in a Community-based context
• Self-awareness and Self-care
Self-awareness and Self-care
Ethical issues
We are bound by the ethical codes of our professions • Respect for dignity, responsible caring, integrity
of relationships, responsibility to society (CPA code)
Additional ethical considerations:
• Understanding and respect for the values and the political and social forces affecting refugee community members
• Culturally appropriate helping models • Interpreters: training, confidentiality, duty to
report
Self-awareness and Self-care
Cultural Competence
• Patients and care providers bring their own cultural perspectives to each encounter
• Culture, religion and ethnicity may influence beliefs and values that people have about mental health
• Although knowing about specific cultures may be helpful, it is also important to avoid overgeneralizing, stereotyping and other assumptions
• While culture does influence development and behaviour, there is significant heterogeneity within any group
Common Factors include developing a therapeutic alliance,
non-judgment, respect, optimism, mutually agreed goals
Self-awareness and Self-care Opportunities for personal growth
• This work can be impactful • Opportunity to understand socio-political
realities that we may be unfamiliar with • We are invited to be mindful of how our own
values and privilege inform our practices
• Self-awareness and self-care are important
Self-awareness and Self-care Appropriate Consultation
• Risk of harm to self or others • Questions about resources, referrals • Questions about treatment planning • Feeling unsure or “stuck”
Please call the Provincial Refugee Mental Health
Coordinator toll-free throughout the province at 1-866-393-3133
When in doubt, consult
Conclusion: Supporting Refugee Mental Health
Screening:
Accurate and rapid identification of needs
Education:
Mental Health Vulnerability in a new environment
Support:
Focused, time-limited intervention, within an interdisciplinary, community-based psychosocial support network
Invitation:
Fostering a sense of trust and empowerment, reducing stigma for future help-seeking
Reflection Activity
Yourself as a Helper
• Why do I want to support refugees? • What strengths do I have that will be useful in this
work?
• What signs should I watch for that I need to seek consultation or attend to my own self care, so that I can work as effectively as possible?
Questions for Discussion and Review
1. What are some of your reflections on the goals of early intervention for refugees?
2. What are some differences between early intervention and trauma-focused therapy?
3. Why is a human rights perspective important in this context?
4. How might you use the Vulnerability Screening Tool in your organization or practice?
Web Resources Refugee Readiness Workshop
UNHCR report: Mental Health of Syrian Refugees http://mhpss.net/?get=250/Culture_mental-health_SyriansFINAL1.pdf
Culturally Safe and Competent Mental Health Care www.multiculturalmentalhealth.ca
Caring for Kids New to Canada
http://www.kidsnewtocanada.ca/culture
Selected Readings Refugee Readiness Workshop
Beiser, M. (2009). Resettling refugees and safeguarding their mental health: lessons learned from the
Canadian Refugee Resettlement Project. Transcultural Psychiatry, 46(4), 539–583
Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees
resettled in western countries: a systematic review. Lancet, 365(9467)
Herman, J. L. (1997). Trauma and Recovery: The Aftermath of Violence - from Domestic Abuse to Political Terror. New York, NY: Basic Books.
Kirmayer, L. J., Guzder, J., & Rousseau, C. (Eds.). (2014). Cultural Consultation: Encountering the Other
in Mental Health Care. New York, NY: Springer.
Miller, K. E., & Rasco, L. M. (2004). The mental health of refugees: ecological approaches to Healing and
adaptation. Mahwah, NJ: Lawrence Erlbaum.
Mollica, R. F. (2008). Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World.
Nashville, TN: Vanderbilt University Press.
Nickerson, A., Bryant, R. A., Silove, D., & Steel, Z. (2011). A critical review of psychological treatments of
posttraumatic stress disorder in refugees. Clinical Psychology Review, 31(3), 399–417.
Rousseau, C., & Drapeau, A. (2004). Premigration Exposure to Political Violence Among Independent
Immigrants and Association With Emotional Distress. Journal of Nervous and Mental Disease, 192(12)
Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical
evidence. Psychological Inquiry, 15(1), 1–18. http://doi.org/10.1207/s15327965pli1501_01
Contact Us
Vancouver Association for Survivors of Torture #301-740 Nicola St./Vancouver, BC
Toll-Free consultation: 1-866-393-3133
Email: [email protected]
Kirby Huminuik, MA, RCC, PhD (Cand.)
Clinical Consultant
Mariana Martinez Vieyra, MA, RCC Provincial Refugee Mental Health Coordinator
