Welcoming refugees home: How a patient-centered medical home can improve care for refugees

Refugee health care is a growing challenge. Access is limited by cultural and language barriers. Refugees are often lost to follow up. Established refugee health programs often refer patients to a variety of providers once initial federally-mandated screening is completed. The Nationalities Service Center (NSC), a resettlement agency, and Jefferson Family Medicine Associates (JFMA) partnered to implement a novel refugee health care protocol. , JFMA, an NCQA-designated patient-centered medical home (PCMH), emphasizes the centrality of the physician-patient relationship by replacing one-time/episodic care for acute illnesses with ongoing coordinated care through utilization of a nurse coordinator, social worker, and NSC liaison. Initial visits are coordinated in dedicated refugee care sessions until patients are integrated as continuity patients with individual providers.

A mixed-method process evaluation (EMR reviews and key informant interviews) was conducted to evaluate clinic effectiveness/efficiency and patient/provider satisfaction and suggestions for clinic improvements. 246 medical charts were reviewed and 21 interviews conducted with 11 key NSC/JFMA providers and a convenience sample of 10 Iraqi refugees. Following initial health screening and vaccinations, 43% refugees made 4 or more visits for ongoing care, and time-to- initial screen improved with 83% seen within the recommended 90 days upon arrival. Findings include the need for enhanced linkages to state/local resources, expansion of the provider base, improvements in provider education/orientation, enhanced refuge patient orientation and communication strategies, ethnic community building, and preferences for trained in-person medical interpreters. As a result of this model, the NSC has been able to resettle refugees with medically complex problems.