Embed Size (px)
Citation preview
Refugee Readiness Workshop: Primary Health Care Part 2: Practical Issues
Martina Scholtens MD CCFP Daniela Widmer RN Mei-ling Wiedmeyer MD CCFP Vancouver Coastal Health April 2016
Workshop Overview
Day 1
● Morning: Pre-Arrival Issues
● Afternoon: Post-Arrival Health Assessment
Day 2
● Practical Issues
o Health insurance
o Interpretation
o Medical visit logistics
o Barriers to care
Health Insurance
● Medical Services Plan (MSP)
● Interim Federal Health (IFH)
● Patient must apply
● Not automatic enrolment!
Medical Services Plan of BC
Patient registration with MSP
● Form must be sent to Health Insurance BC with
copies of each individual’s immigration documents
● Settlement workers help GARs to register
● Private sponsors help PSRs
● Call HIBC at 1-800-663-7100 and ask for an
enrolment specialist with any questions.
Patient registration with MSP
● 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
Refugee Health Vancouver website
● Limited, temporary coverage of health-care
benefits for refugees
● Funded by Citizenship and Immigration Canada
(CIC)
● Administered by Medavie Blue Cross
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)
● Eligible to apply for IFH upon arrival in Canada.
● Enrolment is not automatic
(except for Syrian GARs)
IFH Patient Registration
Patient registration with IFH
● Submit form online or by mail
● Settlement worker or sponsor assists with this
● Activated within days
● Effective for one year for PSRs and GARs
Patient registration with IFH
● 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.
Patient registration with IFH
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 on Medavie Blue Cross website
IFH Coverage
IFH Coverage: Medical Care
● Family physician visits
● Specialist referrals
● Emergency room visits
● Hospital admissions
● Ambulance services
IFH Coverage: Registered Providers
● Providers must register with Medavie Blue Cross
in order to bill IFH for services *
IFH directory on Medavie Blue Cross website
IFH Providers
●Local lists
IFH Providers
● 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, anthelmintics)
● Other medications may be covered with Prior
Approval
IFH Coverage: Medications
● Dental
o Only emergency relief of pain or infection
o Prior approval required for other procedures
● Optometry
oone eye exam & prescription glasses if needed
● Physiotherapy
● Psychology - limited accessibility *
IFH Coverage: Supplemental Services
Provider registration with IFH
Provider registration with IFH
Provider registration with IFH
Patient IFH 101
● Always show IFH paper any time accessing care!
● MSP becomes effective within 3 months
● Show both for 1 year
Patient IFH 101
● Don’t pay for basic health services
o Have contact person if being asked to pay.
o If the patient is billed directly, it is very difficult
to obtain reimbursement.
o MD should note IFH coverage on the
prescription or requisition.
Checklist for sponsors
● 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)
● $1.80/minute
● Average call length for a community family
physician visit is 13 minutes
Provincial Language Service (PLS)
● Interpreters through community settlement
agencies need to be pre-booked
● Familiarize yourself with your community
resources
Interpretation
● PAHA x 2 hours ($29/h)
● Psychiatry
● Psychotherapy
● Need prior approval
● Not for routine medical visits
Interpretation & IFH
Nonprofessional interpreters
If a patient asks to use a nonprofessional third party
to interpret:
● Ensure that the patient is aware of the option to
use PLS
● Have this discussion between the patient, clinician
and PLS phone interpreter, without the third party
present
● Document the patient's choice in the chart
● www.refugeehealth.ca
● ask about literacy
Translated Patient Handouts
Visit Logistics
● Visit length
● Walk in or booked visit
o Interpretation services
● Book patient’s next appointment before they leave
● Interdisciplinary visits - GP/NP, RN, SW…
Visit Logistics
● Consider family visits
o larger physical space
osee family members individually for privacy,
especially women for pregnancy/contraception
needs
● Presence of third party (neighbour, settlement
worker) *
● Debriefing
Privacy & confidentiality
● Patient may feel obligated to allow sponsor or
settlement worker to attend medical visits
● If the third party requests patient information (such
as appointment times or lab results), information
can only be released if the patient gives written
consent
Privacy & confidentiality
● Discuss the patient’s preferences through an
impartial interpreter without the third party
present, ensuring that the patient understands
(s)he is not required to disclose any medical
information to the third party.
● Consider inviting the third party into the room at
the end of the visit, with the patient’s permission
Barriers to Care
Individual Driven
● language and culture
● shame, distrust, fear, denial
● financial
● lack of knowledge of system
Barriers to Care
Provider Driven
● cultural, beliefs
● lack of awareness
● overwhelmed
● lack of financial reimbursement
● lack of support services
Barriers to Care
System Driven
● Complexities of health insurance
Kindness, humility, curiosity and humour go a long
way towards establishing cross-cultural rapport.
Cultural Competency
Copyright UK Department for International Development, CC license.
● “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 Competency Issues
● Questions that start with ‘why’ imply judgment
Avoid the word WHY
Specific to Syrians:
● access to female provider for women
● long hospital gowns
● privacy for vaccinations
Cultural Competency
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
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
Integrated and Interdisciplinary
Facilitating Settlement
• Integrated settlement focused approach
• Safety and material security is a primary goal
• Awareness of social determinants of primary 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)
• Refugees are more likely to seek concrete and
practical support (at least at first)
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
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
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
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?
Mariana Martinez Vieyra, VAST
Session Outline Refugee Readiness Workshop
• Provincial Refugee Mental Health Coordinator
• Working in a Community-based context
• VAST Landing and Settling Group
• Self-awareness and Self-care
Role of the Provincial Mental Health Coordinator
• Provide information, referral and case consultation • Consultation on assessment for vulnerability • Assist with treatment planning • Support with individual and group counselling • Consultation on working with interpreters • Offer opportunity to debrief, bring things down • Site-visits to assist with group development • Facilitate training sessions and presentations
• Provincial Mental Health Toll Free Line 1-866-393-3133
• Importance of a highly coordinated service and support network, with well established referral pathways
• Timely and appropriate referral and follow up
• Trauma- informed settlement / Settlement –
informed trauma counselling services
• Risks of working in isolation- Sustainability
Working in Community-based Context
Interdisciplinary Network
Landing and Settling: VAST Group Therapy Program
Why Groups?
• Build capacity
• Effective use of resources
• Potentially more culturally appropriate
• Integrate settlement and mental health services
• Non-pathologizing approach to mental health
• Trauma-focused approach to settlement
• Settlement frame for Stage I trauma work
Landing and Settling: VAST Group Therapy Program
Psychosocial trauma -focused group for newly-arrived refugees Solution-focused, strengths-based perspective
• Containment, emotional regulation, safety
• Community building
• Sharing experiences, witnessing and normalization
• Information Sharing
• Problem solving, mutual aid, empowerment
• Skills Building
• Psycho Education
• Ongoing assessment
• Referral and Advocacy
• Psycho Education,
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,
dual relationships
Self-awareness and Self-care
Cultural Competence
• Service providers bring their own cultural perspectives to each encounter
• Reflective practice and Self-supervision foremost • Culture, religion and ethnicity influence beliefs and values
that people have about mental health/seeking help • Consider within-group differences . Avoid overgeneralizing,
stereotyping and other assumptions • Use interpreters as cultural consultants
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 • Let us be mindful of how our own values and
privilege inform our practices
• Self-awareness and self-care are foremost
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 challenges do I anticipate?
• What signs should I watch for that I need to seek consultation or attend to my own self care, so that I stay present and grounded in my work?
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
