Case Management for Refugees Can Be Challenging and Rewarding
They need a dose of advocacy with case management
EXECUTIVE SUMMARY
Refugees settling in the United States have multiple health needs and problems that make case management important and challenging.
- The United States takes in about 70,000 refugees each year.
- Many of the people arriving here have complex medical issues, including children with special needs.
- Language, health literacy, and cultural barriers are big issues.
Refugees resettled in the United States often have multiple medical and social-behavioral health needs that require case management. Although their numbers are small in any single community, their needs can be a challenge.
“There are so many issues involved with immigrant and refugee populations seeking healthcare,” says Marcia Carteret, MEd, director of intercultural communications for the Colorado Children’s Healthcare Access Program (CCHAP), and a senior instructor in the department of pediatrics at the University of Colorado School of Medicine in Denver.
Refugees’ barriers to healthcare include cultural challenges in navigating the U.S. healthcare system, language barriers, poverty, and low health literacy, Carteret says. (For more information, see story on cultural barriers in this issue.)
“A large percentage of refugees are at risk because of the combination of these factors,” she says.
About 70,000 refugees have settled in the United States annually in recent years, a small proportion of the more than 60 million refugees worldwide, according to a report by the U.S. Department of State. (The report can be found at: http://bit.ly/2mp8EMa.)
The mostly women and children that arrive in the U.S. often have complex health needs, and they can benefit from case management.
“The big thing they need is advocacy,” says Paige Kolok, MSSW, CSW, care specialist for Passport Health Plan in Louisville, KY. Kolok works mainly with refugee populations on Medicaid, which is available to refugees through the Affordable Care Act (ACA).
“The major thing I do is address barriers to healthcare,” Kolok says. “This population struggles to address barriers themselves due to language and cultural understanding.”
For example, Kolok meets with a refugee family with a high needs child. The child has hydrocephalus and other medical problems. The family has no car, no concept of health insurance, and does not speak English. They do not know the difference between a hospital and a doctor’s office, let alone the differences between family doctors and specialists.
“Maybe they’re talking about seeing their neurologist, and I’m talking about their primary care physician,” Kolok says. “They have a complete unawareness of how things are done.”
Since the child has a wheelchair and transportation is a big issue, it’s very difficult to coordinate care for each provider appointment, she notes.
Case management for the family includes coordinating appointments and transportation that is covered by Medicaid, communicating with transportation to ensure they arrive at scheduled visits on time, and ensuring the various doctors are communicating with one another.
“You have their dental care, physical care, and have to think about mental health,” Kolok says. “A lot of our refugee clients come from a very, very traumatic past, so you have to think about how we’re going to address mental health when there are not enough psychologists and psychiatrists for even the English-speaking clients.”
Another challenge is systemic. Refugees often come from parts of the world where English and Spanish are not taught. Most arrive from Africa, East Asia, and South Asia, and primary care providers do not have staff that can speak their language. While interpreter services are available, these are expensive and sometimes beyond a practitioner’s budget, so they sometimes will turn down refugees as patients.
“Doctors who work in private practice are burdened with so many tasks and requirements that it’s difficult for them to thrive and keep their doors open,” Carteret says.
“It isn’t that providers don’t want to serve these immigrant-refugee patients, but the cost of a telephone interpretive service is prohibitive in the primary care setting,” she adds. “Hospitals spend millions a year on it, and primary care physicians can’t afford to do that.”
From a case manager’s perspective, this obstacle can be challenging. “When I call a doctor’s office and they don’t want to provide services because they don’t want to pay for an interpreter, then part of my job is to educate in a way that shines light on an individual story, so they’ll want to help that person,” Kolok says.
Passport Health Plan pays for a telephone interpreter for Kolok’s clients. The service quickly connects her with an interpreter for any language within minutes.
“Usually we have a three-way call with the client or the client is with me, and we put the interpreter on speakerphone, and it works great,” she says. “That is the most cost-effective way.”
While in-person interpreters are ideal, they’re difficult to find in many areas — especially in rural parts of the country, Kolok and Carteret say.
Even when an immigrant or refugee population grows in an area, finding providers from that community or who speak that population’s first language is difficult.
“In the Denver area, we have a large Somali population, and there are not a lot of Somali physicians licensed and practicing in Colorado,” Carteret says. “We don’t have a lot of physicians who are from any of the ethnic minorities, and that’s just the reality of where we are in terms of recruiting these people into our residencies and medical practices.”
In recent months, Kolok has noticed another issue with her refugee clients: increased anxiety.
For instance, one of Kolok’s clients is Muslim, and she wears the hijab — a head scarf. She confided in Kolok that she is thinking of not wearing her head covering anymore so people won’t know that she’s Muslim.
“That makes me very sad, and I find it heartbreaking that people feel like they can’t wear what they want to wear because they might be targeted,” Kolok says.
Fear of being singled out for harassment is one stressor.
“Most people in America are good-hearted people, and if they just knew the story of one refugee, then of course we’d let that person in our country,” Kolok says. “What kind of person wouldn’t open their arms? The problem is people don’t know their stories; they know fear, and they lump all refugees with ISIS, when they couldn’t be more wrong.”
Another issue is that many of the refugees who have arrived within the past year were separated from members of their family.
“Maybe the mom and kids came over, and the husband is stuck — unable to join them,” Kolok says.
This happened with one client, who has two special needs children. Her husband was not granted refugee status at the same time as the rest of his family. The woman was handling her role as a single parent taking care of children with difficult medical issues, but she thought her husband soon would join them. He had received a letter to move to the United States as a refugee. Then the travel ban was ordered in January, and the family’s reunion was put into limbo, Kolok says.
Even when federal courts put a hold on the travel ban, the husband was unable to travel here. “Just because they lifted the ban doesn’t mean everything is flowing like it was,” she says.
“My client doesn’t know if she’ll ever see her husband again, and now, families are split with uncertain hope of being unified,” she explains. “That’s a great cause of stress, which we all know can severely affect physical wellness.”
In another example, Carteret recalls the case of a family of refugees from Somalia. The mother and her five children, under age 10, were resettled in the U.S. The father was not approved at the same time. Two of their sons spent their entire lives growing up in refugee camps. The mother has no job skills, and she needed to spend all of her time taking care of her children. The travel ban, which includes Somalia, lessened the prospects of her husband joining them.
Divided refugee families also need more case management services because of the unfeasible logistics of managing all of their competing needs.
The single mother of two, for instance, cannot leave one of her children with anyone else because of the language barrier and the challenges of the girl’s severe autism. So she has to bring the girl with her to every medical appointment for herself or her other child, Kolok says.
“Part of my job is to provide relief for the mom,” she says. “I make sure I’m connecting with the mom on a regular basis, and when the daughter — who is a teenager — needs diapers, I have to coordinate with the doctor to get them prescribed.”
Kolok also follows up to make sure the mother is on the bus to get her daughter therapy and to make sure all of the pieces are connected.
“The daughter needs dental care, but she won’t sit still for a dentist, so I have to explain what their options are, and these are all of the pieces that no one else thinks about,” she says. “I try to help her and her children to not fall through the cracks.”
Refugees resettled in the United States often have multiple medical and social-behavioral health needs that require case management. Although their numbers are small in any single community, their needs can be a challenge.
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