Background

Permanently  resettled refugees have been a part of the fabric of Australian society since  the end of the Second World War. Australia’s annual refugee intake will  increase from 13,750 to 18,750 by 2018. Nearly all of these refugees face  substantial health challenges – both from pre-migration trauma, and the demands  of settling in a new and unfamiliar country.

These  challenges are further compounded by a number of challenges at the level of the  health system. Organisations tasked with delivering specialised health services  to refugees are at capacity, processes for transitioning refugee patients from  specialised services to mainstream general practice are inconsistent, and,  mainstream general practice is under-equipped to provide consistently high  quality care to this vulnerable population.

These  systemic weaknesses contribute to poor health outcomes for refugees through  missed opportunities for early intervention and continuity of care, especially  for the prevention and management of long term physical and psychological  conditions. Refugees who fall through the gaps are increasingly turning to  hospital emergency departments for health needs. These needs could be managed  more effectively and at lower cost to the health system through community based  primary care services such as mainstream general practice.

Method

Our unique multi-sectoral partnership aligns 12 national, state and local organisations responsible for delivering community based care to refugees, with an international team of academics. We are working in partnership with refugee focussed health services and mainstream general practice to generate robust, regionally relevant improvements to systems of care for this vulnerable population. We will: a) build the capacity of existing staff in outreach practice facilitation, b) support practice-based quality improvement, c) enhance use of information and communication technology, and d) optimise the use of existing Commonwealth and state resources.

Principles of the work

Two  principles underpin the work: a) Participatory research: where community based  research partnerships built upon on-going knowledge exchange are considered an  essential component of sustainable innovations and, community impact. Our  approach to partnerships and community engagement in shared decision-making  builds on similar experiences within IMPACT; b) Implementation science: our  work has been further informed by the NHMRC framework for designing complex  interventions. Here we acknowledge the complex and multifaceted nature of real world  health interventions, and the need to undertake baseline qualitative and  observational work before proceeding to a definitive trial of a complex  intervention.

Significance

The  project will generate a comprehensive evaluation of the feasibility of  implementing our collaborative approach to building system capacity to deliver  quality, accessible and coordinated PHC care to refugees. Synthesis of findings  will inform a framework to describe how the interventions can be adapted to  local contexts to address a local health system’s priority gaps.

OPTIMISE team program of research and activities

Contextual mapping

Quality improvement  requires an understanding of the nature and severity of specific local problems  and system dysfunction. The effectiveness of complex interventions is dependent  on how widely they are implemented,  which relates to contextual influences at the system, organisational and  individual levels. Hence, we began by mapping these influences on the  performance of primary care for refugees in each of the three Regional  Partnerships.

Mapping  at the system level has enabled us to characterise each region’s refugee population demographic and settlement characteristics, and  measure refugee utilisation of health services including public hospital  Emergency Departments, admissions to hospital, birth outcomes and communicable  disease notifications.

Identifying priority interventions

Our mapping work has generated an understanding of system structure and baseline performance within and between the regions. The data is informing the design of a quality improvement intervention in each of the Regional Partnerships.

We have presented the mapping data at a series of deliberative forums where partners and members of the community had an opportunity to reflect on the data and hence tailor the shape of the quality improvement approach. Participants identified the four following priority areas on which the practice facilitation intervention will focus. They are refugee status recording, interpreter use, conduct of comprehensive physical and mental health assessments, and, appropriate use of referral pathways to other services within the region.

Implementation

We have implemented an outreach practice facilitation intervention where outreach facilitators with expertise in refugee health or general practice will engage clinical and administrative staff within general practices in a series of quality improvement activities. These activities are designed to improve refugee status recording, interpreter use, conduct of comprehensive physical and mental health assessments, and, appropriate use of referral pathways to other services within the region. A total of 31 practices completed the intervention between February, 2019 to August, 2019. This trial is registered with ANZCTR, ACTRN12618001970235.

Evaluation

The study evaluation uses a mixed methods approach consisting of a stepped wedge cluster randomised controlled trial design and an embedded qualitative component. The randomised allocation to early and late implementation stages enables us to make comparisons over time and between regions. The quantitative evaluation of impact will ascertain change in practice performance from baseline against the four priority areas.

An embedded qualitative component  explores the acceptability, usefulness and sustainability of the intervention(s) from the perspectives of clinical and administration practice staff, intervention facilitators, and study research officers.