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Integrated Care Team – Refugee Health Project (Wajma Attayi, Debbie Engel, Lynne Griffiths-Fulton)

We spoke to key partners involved in the Refugee Health Integrated Care Team (ICT) pilot funded by the KW4 OHT, to learn more about the project.


What is the Refugee Health Integrated Care Team?

The Refugee Health Integrated Care Team (ICT) originated as a pilot project with the goal to assist refugee patients transition from the Centre for Family Medicine (CFFM) Family Health Team and from Sanctuary Refugee Health Clinic (now KW Community Healthcaring) into permanent primary care providers within the KW4 area. To achieve this goal the ICT team reached out to non-team based primary care providers, offering them a multi-disciplinary team model approach. This team based model is beneficial for non-team based primary care providers, due to the lack of additional resources offered by this team: a pharmacist, social worker, coordinators, or even system navigators to support with various social determinants of health.


The primary objectives of the project were to facilitate the transition of 300 refugee patients within the first year, offering both patients and non-team-based primary care providers improved access to community resources through a multidisciplinary approach. In addition to providing human health resources, the program included on-demand interpretation services. Together, these resources served as tools to support successful transitions from CFFM and KW Community Healthcaring to permanent primary care providers who were either willing or supportive of taking on refugees into their practices. The final outcomes saw 621 refugee patients successfully discharged from two refugee clinics and 16 Primary Care Practices, all with the invaluable support of the ICT. The project launched in January 2022 and funding ended in January 2023.


Why was the Refugee Health Integrated Care Team (ICT) formed? Who is involved?

CFFM and KW Community Healthcaring were initially conceived as short-term transitional solutions for refugees. However, the issue emerged when these clinics faced the overwhelming challenge of accommodating the growing influx of refugees, exacerbated by the scarcity of primary care providers willing or able to accept new patients into their practices. The limitations in resources and the difficulty in securing permanent primary care providers led to an impasse in service delivery, provoking a call to action. The ICT was the KW4 Ontario Health Team’s first funded project. Expanding on those involved in the Refugee Health Working Group, many organizations came together for the ICT pilot. Center for Family Medicine Family Health Team, KW Community Healthcaring, Camino, Reception House, Home and Community Care Support Services (HCCSS), and the University of Waterloo all worked together. Reception House was involved because of their role as an entry point for new arrivals, specifically Government Assisted Refugees, into Waterloo Region and they referred patients to CFFM. Reception House also provided a different perspective to social services, and some aspects of health care than some of the other organizations who were involved. Camino supported through navigators that assisted patients with social determinants of health needs and connected patients to YMCA for assistance with government forms. Clinical Coordinators were provided by HCCSS to coordinate homecare services for patients who required them. The University of Waterloo were there to support the project as challenges arose and were key in the writing of the final evaluation report.


What are the priorities of the Refugee Health Integrated Care Team?

When speaking with Debbie, Wajma and Lynne, they mentioned five main priorities of the ICT when they began the project. First and foremost, the main priority was to seamlessly transition and have refugee patients securely attached to primary care. To achieve this priority, the team had to focus on finding more doctors to take on refugee patients. The second priority was to remove the stigma and taboo that refugees have complex health issues and are difficult to work with. There are so many success stories of refugees and their levels of resilience that these stigmas of them being ‘difficult’ to manage patients, need to be removed. The ICT group recognized a disconnect in the current system due to lack of communication between the federal and provincial governments.


The third priority is ensuring the federal government is mindful of provincially led clinics. Immigration, Refugee and Canadian Citizenship needs to be aware of these clinics’ services and capacity to properly deliver care. Understanding that the provincial government is responsible for health care and dispersing of those funds, it is both of their roles to communicate and collaborate synergistically, and an example of this could be supplying funding for more human health resource and interpretation services. Additionally, social justice systems can challenge the process of accessing and receiving care. The fourth priority mentioned was including social justice as a lens when evaluating the healthcare system and not just using a health equity lens. Finally, as mentioned, interpretation plays a huge role in the delivery of the ICT's work. Having translation services is essential in enabling the work and ensuring non-native English speakers can advocate for their own healthcare. Ultimately, if there are no interpretation services, there is no equitable care or healthcare. Interpretation is a basic human right.

Did you face any challenges? If so, what were they?

Like any pilot project, there were many challenges that the team faced in delivering these services. But, the ICT team saw these challenges as opportunities for discussion and finding a different perspective. As stated previously, there was a challenge in finding doctors willing to take on patients. Many factors contributed to this challenge as doctors needed to be local, easy to access and ideally speak the one of the top languages of the refugees. Even though there were many doctors who participated in the pilot, they were only able to take on a certain number of patients. At various moments of the pilots, the ICT project experienced standstills due to lack of doctors and have made zero transitions, in one of its latest quarters. Understanding that the non-team based primary care providers do not have this type of team support that can make it difficult to continue providing the necessary additional services. Another challenge that presented itself was the future sustainability of the work.


The OHT funding for the pilot concluded at the end of 2022 and the level of funding presented a number of challenges. The ICT team was able to fund ICT coordinators into 2023 with a grant through the Immigration Partnership Fund of Waterloo region but the coordinators will no longer be employed after December 2023. Many of the other roles such as client navigators and HCCSS coordinators operate in kind, but the ICT coordinator was the vital connection point between the non-team based primary care providers, the team and even the patients themselves. Another challenge faced was the funding of interpretation services. The level of interpretation needed was higher than the funding was able to provide. Interpretation services were provided through the KW Multicultural Centre and the organization was at capacity with the funds they received from Ontario Health. Interpretation services were more likely to be accessed by doctors working in clinics and not sole practitioners.


What are three top takeaways from the ICT’s work?

There were many lessons learned from the ICT project. Pilot projects are trials, a constant journey with many new learnings that will influence future work. It was a quality improvement process that had the team adjusting when they faced challenges and were presented with different perspectives. One of the main takeaways from this project was that there is a clear need for a program like this. The qualitative results had a significant impact for multiple individuals and their families, and can be reviewed in the final report. Even for those that were transitioned out of the temporary clinics to a permanent provider, it will be difficult for them to continue to access that level and quality of care without the support of the ICT program. The second main takeaway is the benefits of all the involved organizations collaborating. They were previously working in isolation to provide their services and intentionally having them work together led to something much more impactful and powerful. The resiliency of the staff working towards the collective mission in easing the transition from clinics to our existing medical system. A third main takeaway was the need to help providers understand the cultural differences and unique needs of refugees, refugee patients may be clinically complex but stable. Their stability was due to education and understanding, with interpretation being key. Interpretation is an important part of that understanding and should be from a third party, not conducted by a family member, all to ensure privacy and confidentiality. Ensuring there is an understanding of the process for both patient and provider guarantees that the transition is as smooth as possible with fewer conflicts. Other key takeaways and learning can be read in the ICT Final Report located on the Reports Page.


Does this working group have any future plans or priorities?

Though the pilot has ended, the group that worked on the ICT hope to continue to work on sustainable solutions in the future, without the need to rely on grant opportunities. The work to date has provided a strong basis for the success of an integrated care team model for refugee patients. They will continue to advocate for a program that assists refugees in finding permanent primary care providers willing to take on patients. Those involved over the past two years will continue to discuss and look at ways to move primary care forward and continue discussions on maintaining integrated care models.

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